A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Rationale:

A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.

B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.

C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.

D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.

Rationale:

A. "Apply the ointment to the skin every 4 hr.": Nitroglycerin topical ointment is applied every 6 to 8 hours, depending on the provider's instructions. Applying it every 4 hours may increase the risk of side effects such as hypotension or tolerance due to excessive dosing frequency.

B. "Spread the ointment in a thin, even layer.": The medication should be applied in a thin, consistent layer to allow for proper absorption through the skin. The dose is usually measured and spread using applicator paper, avoiding rubbing or massaging it in.

C. "Apply the ointment to the forearm.": The preferred application sites are hairless areas of the chest, back, or upper arms. The forearm is not typically used due to variability in absorption and the presence of thinner skin and more movement.

D. "Massage the ointment into the skin.": Nitroglycerin ointment should never be massaged into the skin. Massaging can lead to unpredictable absorption rates and an increased risk of hypotension or headache due to rapid systemic absorption.