CCNS Certified Clinical Nurse Specialist

Answer - C - The most appropriate follow-up question for the nurse to ask is “Do you become short of breath during your normal daily activities?” These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces, causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.