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Difficulty: MediumPhysiological Adaptation

The nursing staff is providing care for a 78-year-old client who is receiving continuous intravenous (IV) hydration therapy for severe gastroenteritis. The client has a documented medical history of congestive heart failure. Upon entering the room, the nurse notes the client is increasingly restless, has developed a frequent moist cough, and reports feeling 'like I cannot catch my breath.' Which immediate actions should the practical nurse take? Select all that apply.

  1. Check the client's peripheral oxygen saturation using a pulse oximeterAnswer
  2. Assist the client into an upright sitting position in bedAnswer
  3. C
    Attribute the client's new onset of restlessness to expected age-related cognitive changes
  4. Listen to the anterior and posterior lung fields for abnormal breath soundsAnswer
  5. E
    Complete a comprehensive peripheral vascular assessment before evaluating respiratory status
  6. F
    Administer a rapid intravenous push of a loop diuretic to reduce systemic fluid volume

Answer

The correct actions are to assist the client into an upright sitting position, check peripheral oxygen saturation, and listen to the lung fields for abnormal breath sounds.
When a client with heart failure receives IV fluids and develops a moist cough and shortness of breath, it strongly indicates fluid volume overload and pulmonary edema. The immediate priority is to support breathing by sitting the client upright. The practical nurse must also promptly collect essential respiratory data, including oxygen saturation and lung auscultation, so accurate information can be immediately reported to the registered nurse or provider for advanced orders.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a history of heart failure, is receiving IV fluids, and is now showing signs of fluid volume overload and pulmonary edema (moist cough, dyspnea, restlessness).
Identifying the underlying complication directs the priority of nursing care.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
Interventions must immediately address the client's breathing difficulties before assessing secondary body systems.
Airway and breathing are always the highest priority in acute status changes.
3
Determine the actions that fall within the practical nurse's scope of practice.
The PN can reposition the client to ease breathing and collect focused respiratory data (SpO2, lung sounds) to urgently report to the RN.
The PN must act rapidly but safely, avoiding interventions that require RN-level credentials (like IV push medications).

Key Concept

Prioritization and Scope of Practice during Acute Pulmonary Edema
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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