When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Choice A reason: Crackles in bilateral lower lobes indicate pulmonary edema in heart failure, where reduced cardiac output causes fluid backup into alveoli, impairing gas exchange and causing dyspnea. This life-threatening emergency requires immediate diuretics or oxygen to reduce preload, preventing respiratory failure or hypoxia, prioritizing intervention.

Choice B reason: A heart rate of 92 beats/minute is normal and not urgent in heart failure, where dyspnea and fatigue suggest fluid overload. Crackles indicate pulmonary edema, a critical issue compromising oxygenation, necessitating immediate action to restore respiratory function, making heart rate less concerning.

Choice C reason: Blood pressure of 138/86 mm Hg is mildly elevated but not critical in heart failure. Crackles signal pulmonary edema, where fluid in alveoli impairs gas exchange, risking hypoxia. This requires urgent intervention like furosemide, as respiratory compromise is more immediate than managing stable blood pressure.

Choice D reason: Peripheral edema 1+ indicates fluid retention in heart failure but is less urgent than crackles, which signify pulmonary edema. Alveolar fluid causes dyspnea and hypoxia, requiring immediate diuretics. Edema is chronic, making respiratory assessment and intervention the priority to prevent acute respiratory failure.

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.