The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Have you been having swelling in your legs?

Have you been experiencing difficulty breathing?

Have you been experiencing chest pain?

Have you been experiencing heart palpitations?

Answer and Explanation

The Correct Answer is B

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Advancing to the bifurcation ensures the balloon is in the bladder but risks over-insertion, potentially damaging the urethra. Proper technique involves advancing 2–3 inches after urine flow to confirm bladder placement, ensuring the balloon inflates safely without obstructing the urethra or causing trauma.

Choice B reason: Instructing pelvic muscle contraction is irrelevant during catheterization, as it does not aid insertion or balloon placement. Pelvic exercises may help post-catheterization for continence but are not part of insertion protocol. The focus is on correct catheter positioning to avoid complications like bladder trauma.

Choice C reason: Bathing the catheter after urine appears is unnecessary and not standard practice. Catheter insertion requires sterile technique, and cleaning occurs before insertion. Post-urine cleaning risks contamination or delay in securing the catheter, potentially causing displacement or infection, making this an incorrect step.

Choice D reason: Advancing the catheter 2–3 inches after urine appears ensures the balloon is fully in the bladder before inflation, preventing urethral trauma or balloon rupture. This standard technique confirms proper placement, as urine flow indicates the catheter tip has reached the bladder, ensuring safe and effective catheterization.

A. Nasal cannula at 2 L/min B. Simple face mask at 8 L/min C. Non-rebreather mask at 15 L/min D. Venturi mask at 40% FiO2

Correct Answer is A

Explanation

Choice A reason: A nasal cannula at 2 L/min delivers low-flow oxygen (24–28% FiO2), suitable for COPD clients to maintain oxygen saturation without suppressing their hypoxic drive. COPD patients rely on low oxygen levels to stimulate breathing, and low-flow oxygen prevents hyperoxia, which could reduce respiratory drive.

Choice B reason: A simple face mask at 8 L/min delivers 40–60% FiO2, which is too high for COPD clients. High oxygen levels can suppress the hypoxic drive, leading to hypoventilation and CO2 retention, worsening respiratory acidosis. Low-flow oxygen is preferred to balance oxygenation and respiratory drive.

Choice C reason: A non-rebreather mask at 15 L/min delivers 60–80% FiO2, inappropriate for COPD clients. High oxygen concentrations risk suppressing the hypoxic drive, causing CO2 retention and respiratory failure. COPD management prioritizes low-flow oxygen to maintain safe oxygenation without disrupting respiratory regulation.

Choice D reason: A Venturi mask at 40% FiO2 delivers precise oxygen concentrations but is still too high for stable COPD clients. High FiO2 can suppress the hypoxic drive, leading to hypoventilation. A nasal cannula at 2 L/min is safer, providing adequate oxygenation while preserving respiratory drive.

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