A patient with a history of chronic heart failure presents to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse perform first?

• A. Auscultate the abdomen
• B. Check the capillary refill
• C. Auscultate the breath sounds
• D. Assess the level of orientation

Answer: (C)

When a patient with chronic heart failure presents with severe dyspnea, the priority is to assess respiratory status to detect signs of pulmonary edema or other airway compromise. Listening to breath sounds immediately provides crucial information about the lungs—crackles from fluid, diminished air entry, or wheezes—that guides urgent interventions such as supplemental oxygen, diuresis, or other treatments.

Auscultating breath sounds directly addresses the patient’s most pressing threat to stability right now: impaired gas exchange. Other actions, like auscultating the abdomen, checking capillary refill, or assessing orientation, don’t give the immediate information needed to manage the dyspnea effectively in this moment.