The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.
Which of the following actions should the nurse take first?

Choice A rationale

Serum electrolyte analysis provides insights into fluid and electrolyte balance but does not specifically diagnose heart failure. Electrolyte changes may occur secondary to heart failure but are not definitive markers for the condition.

Choice B rationale

Complete blood count evaluates for anemia or infection, which may contribute to symptomatology but is not diagnostic for heart failure. Heart failure diagnosis focuses on cardiac-specific markers rather than hematologic parameters.

Choice C rationale

Blood urea nitrogen assesses renal function and reflects perfusion status but lacks specificity for heart failure. Although renal dysfunction may occur in advanced heart failure, BNP measurement is more definitive for cardiac assessment.

Choice D rationale

Brain natriuretic peptide (BNP) is a key diagnostic marker for heart failure. Elevated BNP levels occur due to ventricular stretch and strain associated with fluid overload, a hallmark of heart failure. Normal BNP levels are typically <100 pg/mL, with elevated levels strongly suggesting cardiac dysfunction. .

Choice A rationale

Constant erythema and warmth are more characteristic of venous insufficiency or inflammation, rather than peripheral artery disease. PAD is associated with reduced blood flow and tissue perfusion, leading to symptoms like pallor, coolness, and pain rather than persistent redness and warmth in affected areas.

Choice B rationale

Elevating the legs worsens ischemic pain in PAD by further reducing blood flow. Symptoms typically improve when the legs are in a dependent position due to gravity aiding perfusion. This is a key distinguishing feature in PAD compared to other vascular conditions like venous insufficiency.

Choice C rationale

Discomfort in the legs during exercise relieved by rest, known as intermittent claudication, is a hallmark of PAD. It occurs due to inadequate blood supply during increased activity. Rest restores perfusion and alleviates ischemic pain. This symptom reflects underlying arterial obstruction, a core pathophysiological feature of PAD.

Choice D rationale

Peripheral pulses in PAD are diminished or absent due to arterial obstruction. Bounding pulses in dependent positions suggest venous issues or high cardiac output, not arterial insufficiency. Accurate pulse assessment helps differentiate PAD from other vascular conditions. Normal pulse documentation is critical to diagnosis.