Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Choice A rationale

Refusing to administer the medication without further investigation could jeopardize the client's timely treatment. While safety is paramount, the nurse's initial action should be to gather more information rather than outright refusal, which could delay necessary care.

Choice B rationale

Administering a medication that appears to be abnormally high without verifying the order is unsafe and could lead to serious adverse effects for the client. Nurses have a professional responsibility to question orders that seem incorrect or potentially harmful.

Choice C rationale

Documenting concerns is an important step in the process, but it is not the best *next* action. While documentation is crucial for legal and communication purposes, directly addressing the potentially erroneous order with the prescriber takes precedence to ensure patient safety.

Choice D rationale

Querying the physician about the order is the most appropriate immediate action. This allows the nurse to clarify the dosage, route, and rationale for the high dose. It opens a dialogue with the prescriber to confirm the order's accuracy or identify a potential error, directly addressing the safety concern.

Choice A rationale

Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.

Choice B rationale

Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.

Choice C rationale

Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.

Choice D rationale

Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.