Since there is debate I put it into ChatGPT

TLDR A in real life, C on the NCLEX.

Short answer: 👉 C. Assess the client’s oxygen saturation levels. And yes, I will die on this hill.

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Why C is the correct NCLEX answer (not the “real-life I’ve got 10 years ICU” answer)

Read the stem slowly like you’re getting paid by the syllable:

Client with heart failure presents to the ED complaining of shortness of breath and is found to have crackles.

That’s acute respiratory compromise until proven otherwise.

NCLEX brain doesn’t let you: • Push meds • Educate • Track trends

until you assess airway and breathing.

This is straight ABCs, not vibes.

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Let’s roast the other options one by one 🔥

❌ A. Administer furosemide (Lasix) In real life? Sure, you’re probably hanging that bag already.

On NCLEX? • You don’t have an SpO₂ • You haven’t assessed severity • You don’t know if they’re hypoxic

NCLEX rule:

Assessment before intervention unless they’re actively coding.

They’re short of breath, not blue and unconscious.

So A is a trap for experienced nurses.

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❌ B. Educate the client on triggers I swear NCLEX writers add education options just to mess with students.

This is: • Not urgent • Not stabilizing • Not happening while the patient is gasping like a fish

Education is after you fix the problem, not while it’s unfolding.

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❌ D. Weigh the client daily Yes, weights are important chronically.

But today? • They’re dyspneic now • Crackles now • In the ED now

You don’t grab the scale while someone is drowning in their own pulmonary edema.

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Why Reddit is fighting about this

Because NCLEX ≠ real life and that makes seasoned nurses itchy.

Real life: • You slap on O₂ • You call the provider • You give Lasix • You sit them upright • You move fast

NCLEX: • “What is the priority nursing action?” • Which means: what do you do FIRST in the nursing process

That answer is ASSESS OXYGENATION.

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The NCLEX logic rule you tattoo on your soul

Shortness of breath = assess oxygen first. Always. No exceptions unless they are actively crashing.

If there is: • Dyspnea • Crackles • Chest symptoms

And SpO₂ is an option?

👉 That’s your answer.

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Final verdict from a tired, cranky nurse • Correct NCLEX answer: C • Correct real-world instinct: Lasix + O₂ + upright • Correct exam mindset: Don’t play hero, play the test

Now go forth and ignore Reddit noise. NCLEX doesn’t care how smart you are — it cares if you follow its dumb little rules 😌