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Difficulty: HardPhysiological Adaptation

While conducting afternoon rounds, a practical nurse assesses an elderly client who is receiving continuous intravenous normal saline for dehydration. The client has a documented history of congestive heart failure. The nurse notes the client has developed a new, persistent dry cough and appears increasingly restless. Vital signs show a heart rate of 104 beats/min and a blood pressure of 148/92 mm Hg. Which action should the practical nurse take first?

  1. Auscultate the client's lung fields for adventitious breath soundsAnswer
  2. B
    Administer a prescribed as-needed throat lozenge to relieve the cough
  3. C
    Institute fall precautions and reassure the client that confusion is common
  4. D
    Record the vital signs in the chart and reassess in one hour

Answer

The practical nurse should prioritize auscultating the client's lung fields for adventitious breath sounds to assess for pulmonary edema.
The client is exhibiting early signs of fluid volume overload and impending pulmonary edema, characterized by a new cough, restlessness (an early indicator of hypoxia), tachycardia, and elevated blood pressure. Given the client's history of congestive heart failure and the continuous IV fluid administration, the practical nurse must prioritize airway and breathing. Auscultating the lungs for crackles provides critical focused data that must be immediately reported to the registered nurse or provider for prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and medical history.
The client has a history of congestive heart failure, is receiving continuous IV fluids, and now presents with a new dry cough, restlessness, tachycardia, and hypertension.
Identifying risk factors and early clinical signs is essential for recognizing complications such as fluid volume overload.
2
Apply prioritization frameworks, specifically Airway, Breathing, and Circulation (ABC).
The sudden onset of a cough and restlessness (which is a classic early sign of hypoxia) indicates a potential breathing and airway compromise.
ABC prioritization dictates that respiratory distress must be assessed and addressed before implementing comfort measures or routine monitoring.
3
Determine the most appropriate immediate action within the practical nursing scope of practice.
Auscultating lung sounds allows the nurse to collect critical focused data (e.g., crackles) to report immediately to the registered nurse or healthcare provider.
The practical nurse must gather relevant physiological data rapidly to facilitate necessary emergency medical interventions.

Key Concept

Early Recognition of Fluid Volume Overload and Hypoxia
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Topics

Physiological Adaptation

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