Nclexrn Quiz: Heart Failure Pulmonary Edema Priority Actions
20 questions · exam conditions
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Heart Failure Pulmonary Edema Priority ActionsQuestion 1 of 20

A 62-year-old client with known heart failure presents to the emergency department after missing diuretics for 3 days. Assessment: blood pressure 174/100 mm Hg, heart rate 122/min, respiratory rate 30/min, oxygen saturation 86% on room air, crackles to the apices, and bilateral 2+ edema. Which intervention should the nurse implement IMMEDIATELY?

Apply supplemental oxygen and position the client upright to improve ventilation
Provide medication teaching regarding adherence to diuretics and low-sodium diet
Obtain a comprehensive health history including recent fluid intake and diet
Administer intravenous furosemide after obtaining a provider order
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Nclexrn Quiz: Heart Failure Pulmonary Edema Priority Actions

Practice Heart Failure Pulmonary Edema Priority Actions in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Heart Failure Pulmonary Edema Priority Actions, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Question 1

A 62-year-old client with known heart failure presents to the emergency department after missing diuretics for 3 days. Assessment: blood pressure 174/100 mm Hg, heart rate 122/min, respiratory rate 30/min, oxygen saturation 86% on room air, crackles to the apices, and bilateral 2+ edema. Which intervention should the nurse implement IMMEDIATELY?

  1. Apply supplemental oxygen and position the client upright to improve ventilation (correct answer)
  2. Provide medication teaching regarding adherence to diuretics and low-sodium diet
  3. Obtain a comprehensive health history including recent fluid intake and diet
  4. Administer intravenous furosemide after obtaining a provider order
Explanation: This question tests prioritization and clinical judgment in managing acute exacerbation of heart failure due to medication nonadherence. It utilizes the ABC priority framework to address impaired breathing and oxygenation. Applying supplemental oxygen and positioning the client upright to improve ventilation is the immediate action because it tackles hypoxemia (86%), crackles, and dyspnea directly. Medication teaching (B) and history (C) are educational; administering furosemide (D) requires order and delays ABCs. The principle is to stabilize acute symptoms before addressing causes like missed diuretics. This follows Maslow's physiological needs. A transferable strategy is to prioritize oxygenation in nonadherent clients presenting with decompensation.

Question 2

A 66-year-old postoperative client with a history of heart failure is receiving maintenance intravenous fluids at 125 mL/hr. The client develops dyspnea and cough. Assessment: blood pressure 162/90 mm Hg, heart rate 110/min, respiratory rate 26/min, oxygen saturation 89% on room air, crackles at bases, and new 2+ edema. What is the nurse's PRIORITY action for this client?

  1. Slow the intravenous fluid rate, elevate the head of the bed, and apply supplemental oxygen (correct answer)
  2. Request a chest radiograph to evaluate for atelectasis and review the client's intake and output record
  3. Provide teaching on incentive spirometry to improve lung expansion and encourage coughing and deep breathing
  4. Administer the next scheduled dose of oral beta-blocker to reduce heart rate and monitor oxygen saturation
Explanation: With a history of heart failure, this client's dyspnea, crackles, edema, and oxygen saturation of 89% indicate acute fluid overload progressing to pulmonary edema. The priority is to address the threat to breathing and circulation by stopping the intravenous fluid that is driving it, placing the client upright, and giving oxygen. A chest radiograph and intake/output review can help explain atelectasis or fluid balance, but they are diagnostic and do not immediately improve oxygenation or reduce preload. Incentive spirometry and coughing are helpful for preventing atelectasis, but they are not an emergency response to pulmonary edema. The oral beta-blocker may lower heart rate, but it does not remove excess volume or correct hypoxemia, and in acute decompensated heart failure it may need to be withheld rather than given. Therefore, the only choice that directly counteracts the cause and supports the ABCs is slowing the IV fluid rate, elevating the head of the bed, and applying supplemental oxygen.

Question 3

A 73-year-old client with heart failure is being discharged from an acute care unit. The client suddenly becomes short of breath while dressing. Assessment: oxygen saturation 84% on room air, respiratory rate 32/min, heart rate 120/min, blood pressure 168/94 mm Hg, crackles throughout, and pink frothy sputum. Which intervention should the nurse implement IMMEDIATELY?

  1. Have the client lie flat to reduce oxygen demand and conserve energy
  2. Apply oxygen, place the client upright, and activate the rapid response team (correct answer)
  3. Recheck oxygen saturation with a different pulse oximeter probe
  4. Call the provider to request orders for intravenous diuretics and nitrates
Explanation: This question tests prioritization and clinical judgment in managing sudden pulmonary edema during discharge in a client with heart failure. It uses the ABC framework to address acute respiratory compromise. Applying oxygen, placing the client upright, and activating the rapid response team is the highest priority because it corrects hypoxemia (84%), crackles, and frothy sputum, stabilizing the client emergently. Lying flat (A) worsens symptoms; rechecking saturation (C) delays action; calling for orders (D) bypasses immediate team support. The principle is to recognize flash pulmonary edema and escalate care rapidly. This aligns with safety protocols for decompensation. A transferable strategy is to activate rapid response for sudden ABC changes in heart failure clients.

Question 4

A 75-year-old client with heart failure is admitted for fluid overload. The provider writes new orders. Current assessment: respiratory rate 28/min, oxygen saturation 87% on 2 L nasal cannula, crackles to mid-lung fields, blood pressure 156/88 mm Hg. The nurse should QUESTION which order given the client's condition?

  1. Administer intravenous furosemide now
  2. Restrict fluids to 1.5 L/day
  3. Infuse 0.9% sodium chloride 1,000 mL bolus over 1 hour (correct answer)
  4. Apply oxygen to maintain oxygen saturation at or above 92%
Explanation: This question tests prioritization and clinical judgment in evaluating provider orders for a client with heart failure and fluid overload. It employs safety principles to identify inappropriate interventions that could worsen the condition. Infusing 0.9% sodium chloride 1,000 mL bolus over 1 hour should be questioned because it exacerbates fluid overload amid crackles and low saturation (87%), risking further pulmonary edema. Administering furosemide (A) promotes diuresis; restricting fluids (B) reduces intake; applying oxygen (D) supports breathing. The decision-making principle is to challenge orders contradicting the client's volume status. This aligns with nursing advocacy for patient safety. A transferable strategy is to question volume-expanding orders in overloaded heart failure clients.

Question 5

A 65-year-old client with heart failure is on a medical-surgical unit. After receiving a 500 mL intravenous fluid bolus for dizziness, the client develops shortness of breath. Assessment: blood pressure 160/92 mm Hg, heart rate 116/min, respiratory rate 28/min, oxygen saturation 88% on room air, crackles at bases, and new cough. Which intervention should the nurse implement IMMEDIATELY?

  1. Auscultate lung sounds again after having the client use the incentive spirometer
  2. Stop or slow the intravenous fluids, raise the head of the bed, and apply supplemental oxygen (correct answer)
  3. Teach the client to avoid excess fluids and to weigh daily at home
  4. Delegate to assistive personnel to obtain orthostatic blood pressures
Explanation: This question tests prioritization and clinical judgment in managing fluid bolus-induced dyspnea in heart failure. It employs the ABC framework to address breathing and circulation. Stopping or slowing the intravenous fluids, raising the head of the bed, and applying supplemental oxygen is the immediate action because it counters overload causing hypoxemia (88%), crackles, and cough. Auscultating after spirometry (A) delays; teaching (C) is discharge-focused; delegating orthostatics (D) assesses but not intervenes. The principle is to halt contributing factors like fluids in symptomatic clients. This promotes safety from iatrogenic harm. A transferable strategy is to adjust infusions first in volume-sensitive conditions.

Question 6

A 77-year-old client with heart failure and pulmonary edema is on oxygen and awaiting transfer to a higher level of care. Assessment: oxygen saturation 86% on nonrebreather mask, respiratory rate 36/min, heart rate 134/min, blood pressure 178/102 mm Hg, and increasing confusion. What is the nurse's PRIORITY action for this client?

  1. Reorient the client to person, place, and time and reduce environmental stimulation to decrease anxiety
  2. Prepare for escalation of respiratory support and notify the provider/rapid response due to worsening hypoxemia (correct answer)
  3. Obtain a full neurological assessment, including cranial nerve and motor checks, to rule out stroke as the cause of confusion
  4. Delegate to assistive personnel to obtain a fingerstick blood glucose level to rule out hypoglycemia as a cause of confusion
Explanation: The client has severe hypoxemia (SpO2 86% on a nonrebreather), tachypnea, tachycardia, and worsening confusion—a picture of impending respiratory failure. The nurse's priority is to protect airway, breathing, and circulation: prepare for more advanced respiratory support and activate the provider or rapid response team. Reorienting the client and reducing environmental stimulation might be comforting but leaves the underlying oxygen deficit untreated and can delay rescue. Performing a full neurological assessment to rule out stroke is a tempting response to confusion, yet the confusion is best explained by hypoxemia and hypercapnia from pulmonary edema; a lengthy neuro exam is not the first action while ventilation is threatened. Checking a fingerstick blood glucose is part of an altered-mentation workup, but it is not the priority when the client is visibly hypoxemic; delegating it now takes time away from escalating care. Move first on oxygenation, then reassess.

Question 7

A 73-year-old client with known heart failure is admitted with acute pulmonary edema. Assessment: respiratory rate 32/min, oxygen saturation 84% on 6 L/min nasal cannula, heart rate 124/min, blood pressure 178/96 mm Hg, and crackles throughout both lungs; the client is restless and cannot lie flat. The provider is at the bedside and gives several verbal orders. Which intervention should the nurse implement IMMEDIATELY?

  1. Administer intravenous morphine as prescribed for anxiety
  2. Apply a nonrebreather mask and prepare for possible noninvasive ventilation (correct answer)
  3. Insert a urinary catheter to measure hourly urine output
  4. Obtain a baseline daily weight and measure abdominal girth
Explanation: This question tests prioritization and clinical judgment in managing acute pulmonary edema with severe hypoxia. The priority framework is ABCs, focusing on the immediate threat to breathing and oxygenation. Applying a nonrebreather mask and preparing for possible noninvasive ventilation (Option B) is the highest priority because the client has severe hypoxia (SpO2 84% on 6L) requiring immediate escalation of oxygen delivery to prevent respiratory failure. Morphine (Option A) can help with anxiety but may depress respirations in this compromised state; urinary catheter insertion (Option C) and obtaining weights (Option D) are important but secondary to stabilizing oxygenation. The decision-making principle is that severe hypoxia unresponsive to moderate oxygen flow requires immediate escalation to high-flow oxygen delivery systems and preparation for ventilatory support. The transferable strategy is: in acute pulmonary edema with hypoxia despite oxygen therapy, immediately maximize oxygen delivery before pursuing other interventions.

Question 8

A 67-year-old client with heart failure is receiving oxygen at 6 L/min by nasal cannula. The client becomes increasingly dyspneic after returning from radiology. Assessment: respiratory rate 32/min, oxygen saturation 83%, heart rate 126/min, blood pressure 170/96 mm Hg, and crackles throughout. Which intervention should the nurse implement IMMEDIATELY?

  1. Increase oxygen delivery by switching to a nonrebreather mask and position upright (correct answer)
  2. Obtain a stat serum brain natriuretic peptide level to trend heart failure severity
  3. Document the findings and recheck vital signs in 15 minutes
  4. Delegate to assistive personnel to bring the client water to relieve dry mouth
Explanation: This question tests prioritization and clinical judgment in managing worsening dyspnea post-activity in a client with heart failure. It applies the ABC framework to correct acute hypoxemia. Increasing oxygen delivery by switching to a nonrebreather mask and positioning upright is the immediate action because it addresses dropping saturation (83%) and crackles, enhancing ventilation. Obtaining BNP (B) is diagnostic; documenting and rechecking (C) delays; delegating water (D) is irrelevant. The principle is to escalate oxygen for transport-induced decompensation. This ensures safety during transitions. A transferable strategy is to prioritize oxygen modality changes in acute desaturation events.

Question 9

A 71-year-old client with chronic heart failure in a skilled nursing facility reports needing to sleep on three pillows and waking up gasping for air. Assessment: respiratory rate 24/min, oxygen saturation 90% on room air, heart rate 104/min, blood pressure 142/86 mm Hg, crackles at bases, and 2+ ankle edema. What is the nurse's PRIORITY action for this client?

  1. Place the client in high-Fowler position and apply supplemental oxygen per facility protocol (correct answer)
  2. Schedule physical therapy to address deconditioning and fatigue
  3. Provide teaching about limiting sodium intake and reading food labels
  4. Delegate to assistive personnel to obtain a weekly weight and record it in the chart
Explanation: This question tests prioritization and clinical judgment in managing orthopnea in chronic heart failure in a skilled nursing facility. It uses the ABC framework, focusing on breathing difficulties indicated by symptoms. Placing the client in high-Fowler position and applying supplemental oxygen per facility protocol is the priority because it alleviates orthopnea, crackles, and low saturation (90%), improving gas exchange. Scheduling physical therapy (B) and teaching (C) are rehabilitative; delegating weights (D) is monitoring. The principle is to address paroxysmal nocturnal dyspnea immediately to prevent escalation. This prioritizes physiological stability. For similar situations, intervene on positioning and oxygen before long-term planning.

Question 10

A 74-year-old client with heart failure is admitted with pulmonary edema and is anxious and restless. Assessment: oxygen saturation 81% on room air, respiratory rate 34/min, heart rate 130/min, blood pressure 182/104 mm Hg, crackles throughout, and audible gurgling respirations. What is the nurse's PRIORITY action for this client?

  1. Administer an anti-anxiety medication as prescribed to reduce oxygen demand and lower the client's heart rate.
  2. Perform a focused cardiac assessment and review the medication reconciliation to identify the cause of the exacerbation.
  3. Position the client upright and apply high-flow oxygen while preparing suction equipment. (correct answer)
  4. Obtain a urine specimen to evaluate kidney function before initiating diuretic therapy for the pulmonary edema.
Explanation: Airway and oxygenation are the immediate priorities. This client has audible gurgling respirations, widespread crackles, and an oxygen saturation of 81%, so the nurse must first position him upright to improve ventilation, deliver high-flow oxygen to correct hypoxemia, and have suction ready in case secretions obstruct the airway. The anti-anxiety medication may reduce distress but does not clear the airway or improve oxygenation, and sedation can depress respirations. Performing a focused cardiac assessment and medication reconciliation is useful later, but it delays the critical intervention while the client is in acute respiratory distress. Obtaining a urine specimen may be needed before diuretic therapy, but it is not the priority when airway and breathing are threatened. Only the airway/oxygenation intervention directly addresses the life-threatening findings.

Question 11

A 69-year-old post-operative client (abdominal surgery 2 days ago) with a history of heart failure is receiving intravenous maintenance fluids at 125 mL/hr. The client now reports shortness of breath and has frothy sputum. Assessment: respiratory rate 32/min, oxygen saturation 86% on 4 L/min nasal cannula, heart rate 116/min, blood pressure 162/94 mm Hg, crackles throughout, and jugular venous distention. Which intervention should the nurse implement IMMEDIATELY?

  1. Stop the intravenous fluids and keep the vein open with a saline lock per facility protocol (correct answer)
  2. Obtain an order for a B-type natriuretic peptide level to evaluate the client's fluid status before changing therapy
  3. Encourage coughing and deep breathing to mobilize the secretions causing the client's respiratory distress
  4. Delegate application of antiembolism stockings to the nursing assistant to prevent deep vein thrombosis
Explanation: This client has acute pulmonary edema from rapid fluid overload — frothy sputum, hypoxia, crackles, tachypnea, and JVD all point to it — and the IV maintenance fluid is the source. Stopping the intravenous fluids and keeping the vein open with a saline lock is the immediate priority because it removes the cause of the respiratory compromise while preserving IV access for treatment. Obtaining a B-type natriuretic peptide level only delays action: the clinical picture already establishes fluid overload, and a lab result will not remove the fluid. Encouraging coughing and deep breathing targets secretions, but this is alveolar fluid from heart failure, not mucus plugging, and the effort can worsen hypoxemia. Delegating antiembolism stockings addresses DVT prophylaxis, which is unrelated to this acute crisis. The transferable principle: in a client with heart failure, signs of pulmonary edema during an IV infusion mean stop the fluid source first — before diagnostics, comfort measures, or routine prophylaxis.

Question 12

A 68-year-old postoperative day 1 client after hip repair has a history of heart failure with reduced ejection fraction and received 2 L of intravenous fluids overnight for hypotension. Current findings: blood pressure 148/86 mm Hg, heart rate 112/min, respiratory rate 28/min, oxygen saturation 88% on 2 L nasal cannula, new crackles at bases, and jugular venous distention. What is the nurse's PRIORITY action for this client?

  1. Increase oxygen delivery and raise the head of the bed, then notify the provider of suspected fluid overload (correct answer)
  2. Encourage oral fluids in small, frequent amounts to maintain renal perfusion and prevent acute kidney injury after the overnight fluid replacement
  3. Obtain a detailed pain assessment and administer the prescribed opioid analgesic to reduce postoperative pain and lower heart rate
  4. Request a dietary consult for a low-sodium diet and fluid restriction teaching once the client is stabilized from this event
Explanation: This client has acute respiratory compromise from fluid overload: SpO2 88%, crackles, JVD, tachycardia, and tachypnea after aggressive IV fluids in a setting of reduced ejection fraction. The priority is to relieve hypoxemia and reduce cardiac workload. Raising the head of the bed and increasing oxygen delivery directly address breathing and circulation; notifying the provider of suspected fluid overload starts treatment of the cause. Encouraging oral fluids is harmful because it adds volume to an already overloaded circulation and can worsen pulmonary edema. Obtaining a pain assessment and giving an opioid are not indicated: there are no pain indicators, and opioids can blunt respiratory drive. Requesting dietary teaching is a reasonable long-term measure, not an immediate action during acute decompensation. The correct choice uses the ABC framework and recognizes iatrogenic volume overload before pulmonary edema progresses.

Question 13

A 78-year-old client with chronic heart failure in a long-term care facility has new confusion and worsening shortness of breath today. Assessment: temperature 36.8°C (98.2°F), blood pressure 144/82 mm Hg, heart rate 110/min, respiratory rate 28/min, oxygen saturation 87% on room air, crackles at bases, and 2+ edema. Which assessment finding requires the nurse to act FIRST?

  1. 2+ bilateral lower-extremity edema with pitting that extends up to the knees
  2. New confusion with oxygen saturation 87% on room air (correct answer)
  3. Heart rate of 110/min with a regular rhythm on the monitor
  4. Temperature 36.8°C (98.2°F), verified on a repeat tympanic reading
Explanation: The priority is the finding that threatens oxygenation and tissue perfusion. In an older adult with worsening heart failure, new confusion combined with oxygen saturation 87% on room air is a strong warning that hypoxemia is severe enough to impair cerebral function, so this requires the nurse to act first. The 2+ bilateral lower-extremity edema with pitting to the knees is a sign of fluid overload, but peripheral edema alone is not an immediate threat to oxygenation or mentation and can be addressed after the hypoxemia is managed. The heart rate of 110/min with a regular rhythm is most likely a compensatory mechanism; the priority is to correct the oxygen deficit rather than treat a regular tachycardia seen in response to it. The temperature of 36.8°C (98.2°F) is a normal value and does not suggest an acute febrile or infectious emergency. Therefore, the correct first action is aimed at the hypoxemia and neurologic change.

Question 14

A 64-year-old client arrives in the emergency department with a history of heart failure and reports sudden severe shortness of breath that started 30 minutes ago while lying down to sleep. Assessment: anxious, speaking in one-word sentences; respiratory rate 36/min; oxygen saturation 78% on nonrebreather mask at 15 L/min; heart rate 132/min; blood pressure 204/110 mm Hg; crackles throughout both lungs; skin cool and diaphoretic. What is the nurse's PRIORITY action for this client?

  1. Insert an indwelling urinary catheter to monitor urine output
  2. Prepare for noninvasive positive-pressure ventilation and notify respiratory therapy (correct answer)
  3. Obtain a complete medication history and last diuretic dose
  4. Request an order for a chest radiograph before initiating further interventions
Explanation: This question tests prioritization and clinical judgment in managing severe acute pulmonary edema with impending respiratory failure. The priority framework is ABCs, specifically addressing imminent respiratory failure despite maximal oxygen therapy. Preparing for noninvasive positive-pressure ventilation and notifying respiratory therapy (Option B) is the highest priority because the client shows signs of respiratory failure (SpO2 78% on 15L nonrebreather, one-word sentences, RR 36) requiring immediate ventilatory support. Inserting a urinary catheter (Option A) can wait and won't address the respiratory crisis; obtaining medication history (Option C) is important but secondary to stabilizing breathing; requesting a chest X-ray (Option D) delays critical intervention. The decision-making principle is that when maximal oxygen therapy fails to maintain adequate oxygenation in acute pulmonary edema, immediate ventilatory support is required to prevent intubation. The transferable strategy is: recognize that hypoxia unresponsive to high-flow oxygen with severe respiratory distress indicates the need for immediate advanced respiratory support.

Question 15

A 61-year-old client with heart failure is on a medical unit receiving oxygen at 2 L/min nasal cannula. After returning from the bathroom, the client becomes acutely short of breath. Assessment: respiratory rate 30/min, oxygen saturation 85%, heart rate 120/min, blood pressure 170/98 mm Hg, and new crackles in all lung fields; the client is coughing up pink-tinged sputum. What is the nurse's PRIORITY action for this client?

  1. Increase oxygen delivery and place the client in an upright position (correct answer)
  2. Notify the provider and request an order for a stat chest radiograph
  3. Assess for dependent edema and obtain the client's current weight
  4. Delegate vital sign reassessment to the unlicensed assistive personnel
Explanation: This question tests prioritization and clinical judgment in managing acute pulmonary edema with pink-tinged sputum. The priority framework is ABCs, addressing the immediate threat to breathing from severe pulmonary congestion. Increasing oxygen delivery and placing the client in an upright position (Option A) is the highest priority because it immediately addresses the critical hypoxia (SpO2 85%) and helps reduce pulmonary congestion while the pink-tinged sputum indicates severe pulmonary edema requiring urgent intervention. Notifying the provider for chest X-ray (Option B) delays immediate treatment; assessing edema and weight (Option C) is important but not urgent; delegating vital signs (Option D) doesn't address the crisis. The decision-making principle is that pink-tinged or frothy sputum with severe hypoxia indicates life-threatening pulmonary edema requiring immediate respiratory support. The transferable strategy is: recognize pink/frothy sputum as a critical sign requiring immediate oxygenation and positioning interventions.

Question 16

A 79-year-old client in a long-term care facility has chronic heart failure and has had gradually worsening fatigue and swelling over 2 weeks. Today the client is more short of breath at rest. Assessment: respiratory rate 30/min, oxygen saturation 89% on room air, heart rate 104/min, blood pressure 146/84 mm Hg, bilateral crackles halfway up the lungs, 3+ pitting edema, and weight gain of 3.2 kg (7 lb) in 10 days. Which intervention should the nurse implement IMMEDIATELY?

  1. Review the medication administration record for missed doses of diuretics
  2. Start oxygen therapy and position the client upright to improve ventilation (correct answer)
  3. Provide teaching on daily weights and sodium restriction
  4. Delegate measurement of the client's calf circumference to the nursing assistant
Explanation: This question tests prioritization and clinical judgment in managing decompensated heart failure with respiratory compromise. The priority framework is ABCs, focusing on the immediate breathing threat from pulmonary congestion. Starting oxygen therapy and positioning the client upright (Option B) is the highest priority because it directly addresses the hypoxia (SpO2 89%) and tachypnea while helping reduce pulmonary congestion through gravity-assisted venous pooling. Reviewing missed diuretics (Option A) is important for understanding the cause but doesn't provide immediate relief; teaching (Option C) is inappropriate during acute distress; delegating calf measurements (Option D) addresses assessment but not the urgent respiratory compromise. The decision-making principle is that gradual worsening of heart failure symptoms culminating in respiratory distress requires immediate intervention to prevent further decompensation. The transferable strategy is: in chronic heart failure exacerbations with respiratory compromise, always address oxygenation and positioning first, then investigate causes and implement medical management.

Question 17

A 75-year-old client with chronic heart failure is in a long-term care facility and has increasing dyspnea and swelling. Assessment: oxygen saturation 90% on room air, respiratory rate 24/min, heart rate 96/min, blood pressure 138/80 mm Hg, 3+ pitting edema, and reports sleeping in a recliner for the past week. The nurse notes the client is confused compared with baseline and is using accessory muscles to breathe. Which assessment finding requires the nurse to act FIRST?

  1. 3+ pitting edema in both lower extremities
  2. Sleeping in a recliner for the past week
  3. New confusion with accessory muscle use during breathing (correct answer)
  4. Heart rate 96/min with blood pressure 138/80 mm Hg
Explanation: This question tests prioritization and clinical judgment in recognizing signs of hypoxia-induced altered mental status in heart failure. The priority framework is ABCs, specifically addressing compromised oxygenation affecting brain function. New confusion with accessory muscle use during breathing (Option C) requires immediate action because it indicates severe hypoxia causing altered mental status and increased work of breathing, suggesting impending respiratory failure. The 3+ pitting edema (Option A) and orthopnea requiring recliner sleeping (Option B) are concerning but chronic; vital signs (Option D) are relatively stable. The decision-making principle is that mental status changes in heart failure often indicate hypoxia or hypoperfusion requiring urgent intervention to prevent further deterioration. The transferable strategy is: always prioritize new neurological changes in cardiac clients as they often indicate inadequate oxygenation or perfusion requiring immediate intervention.

Question 18

A 70-year-old client with chronic heart failure is admitted for worsening dyspnea and is now acutely anxious with increased work of breathing. Findings: blood pressure 158/92 mm Hg, heart rate 118/min, respiratory rate 30/min, oxygen saturation 85% on 4 L nasal cannula, crackles to mid-lung fields, and cool clammy skin. Which intervention should the nurse implement IMMEDIATELY?

  1. Call respiratory therapy to perform a nebulizer treatment for wheezing
  2. Switch to a nonrebreather mask and position the client upright (correct answer)
  3. Ask the client to rate anxiety and provide guided breathing techniques
  4. Delegate to assistive personnel to obtain a bedside weight and measure urine output
Explanation: This question tests prioritization and clinical judgment in managing acute anxiety and dyspnea in a client with chronic heart failure. It utilizes the ABC priority framework to address hypoxemia and increased work of breathing. Switching to a nonrebreather mask and positioning the client upright is the immediate intervention because it optimizes oxygenation (85% saturation) and reduces preload amid crackles and clammy skin. Calling for nebulizer (A) assumes wheezing without mention; anxiety rating and breathing techniques (C) are secondary to oxygenation; delegating weight and output (D) is monitoring, not acute. The principle is to correct hypoxemia first, as it exacerbates anxiety and distress. This follows Maslow's by meeting basic physiological needs. A transferable strategy is to escalate oxygen delivery and positioning before other interventions in decompensating heart failure.

Question 19

A 61-year-old client with heart failure presents to the emergency department with acute dyspnea after shoveling snow. Assessment: blood pressure 186/106 mm Hg, heart rate 128/min, respiratory rate 34/min, oxygen saturation 80% on room air, crackles throughout, and pale diaphoretic skin. Which intervention should the nurse implement IMMEDIATELY?

  1. Place the client on continuous cardiac monitoring and obtain a 12-lead electrocardiogram
  2. Apply oxygen and prepare for noninvasive positive pressure ventilation as indicated (correct answer)
  3. Obtain a detailed history of activity intolerance and medication adherence
  4. Start an intravenous line and send labs including troponin and brain natriuretic peptide
Explanation: This question tests prioritization and clinical judgment in managing activity-induced pulmonary edema in heart failure. It utilizes the ABC framework for severe respiratory distress. Applying oxygen and preparing for noninvasive positive pressure ventilation as indicated is the immediate action because it corrects hypoxemia (80%), crackles, and diaphoresis, averting failure. Monitoring and ECG (A) assess; history (C) is secondary; labs (D) diagnose but delay. The principle is to anticipate ventilatory needs in exertional decompensation. This ensures emergency safety. For similar cases, prepare advanced respiratory support early in high-risk presentations.

Question 20

A 72-year-old client with a history of systolic heart failure is on a telemetry unit and suddenly reports severe shortness of breath after walking to the bathroom. Assessment: blood pressure 176/98 mm Hg, heart rate 124/min, respiratory rate 34/min with pink frothy sputum, oxygen saturation 82% on room air, crackles throughout both lungs. Which intervention should the nurse implement IMMEDIATELY?

  1. Prepare the client for a stat portable chest radiograph and arterial blood gas draw
  2. Place the client in high-Fowler position with legs dependent and apply oxygen via nonrebreather mask (correct answer)
  3. Delegate to the assistive personnel to obtain a full set of daily weights and intake/output totals
  4. Administer the scheduled oral furosemide and reassess breath sounds in 30 minutes
Explanation: This question tests prioritization and clinical judgment in managing acute pulmonary edema in a client with heart failure. It utilizes the ABC (airway, breathing, circulation) priority framework to address immediate threats to oxygenation. Placing the client in high-Fowler position with legs dependent and applying oxygen via nonrebreather mask is the highest priority action because it immediately improves oxygenation and reduces preload by promoting venous pooling in the legs, alleviating respiratory distress. Preparing for a chest radiograph and arterial blood gases (A) is diagnostic but not immediate; delegating for weights and intake/output (C) addresses monitoring but delays acute intervention; administering furosemide and reassessing later (D) is therapeutic but not the first step in stabilizing breathing. The decision-making principle here is to intervene first on impaired gas exchange, as hypoxemia (oxygen saturation 82%) and crackles indicate acute decompensation. This follows Maslow's hierarchy by prioritizing physiological needs like oxygenation over diagnostic or monitoring actions. A transferable prioritization strategy is to always address life-threatening respiratory compromise in heart failure exacerbations before pursuing diagnostics or medications.