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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is providing care for an older adult client who suddenly develops a moist cough, increased work of breathing, and new-onset confusion while receiving a continuous intravenous fluid infusion. Which of the following actions should the PN take? Select all that apply.

  1. Position the client upright in a high-Fowler's position.Answer
  2. Obtain a current pulse oximetry reading and assess lung sounds.Answer
  3. Pause the intravenous fluid infusion and urgently alert the supervising registered nurse.Answer
  4. D
    Offer the client a prescribed oral sedative to manage their sudden agitation.
  5. E
    Explain to the family that the sudden confusion is an expected age-related change.
  6. F
    Plan to recheck the client's vital signs in one hour to see if the rapid breathing improves.

Answer

The correct actions are positioning the client upright in a high-Fowler's position, obtaining a pulse oximetry reading with lung sounds, and pausing the intravenous fluid infusion while alerting the registered nurse.
The client is presenting with classic manifestations of fluid volume overload complicated by pulmonary edema, which impairs gas exchange and leads to hypoxia (evidenced by the new-onset confusion). The immediate nursing priorities are to support the client's breathing by sitting them upright, to gather objective respiratory data to pass on to the medical team, and to halt the IV fluid infusion that is actively worsening the fluid overload. Rapid escalation to the RN is required because the client is unstable and requires advanced care.

Step-by-Step Solution

1
Analyze the clinical cues in the scenario.
The combination of a moist cough, increased work of breathing, and new-onset confusion during IV fluid therapy strongly points to fluid volume overload leading to pulmonary edema and hypoxia.
Recognizing patterns of physiological decline is the first step in prioritizing clinical judgment.
2
Prioritize actions based on the ABCs (Airway, Breathing, Circulation).
Positioning the client upright is the fastest independent intervention the PN can perform to optimize breathing and lung expansion.
Mechanical positioning immediately reduces the work of breathing without requiring an order.
3
Remove the suspected cause of the decompensation.
Pausing the continuous IV fluid infusion prevents additional fluid accumulation in the lungs.
Continuing fluids in the presence of pulmonary edema will worsen the client's respiratory failure.
4
Gather data and escalate.
Checking oxygen saturation and lung sounds provides specific data to report to the RN, who must be alerted immediately to initiate medical interventions (like diuretics or advanced oxygen therapy).
The client is unstable, requiring prompt RN and provider involvement.

Key Concept

Physiological Adaptation: Acute Fluid Volume Overload and Pulmonary Edema
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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