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Difficulty: EasyPhysiological Adaptation

A client with a history of heart failure is receiving a continuous intravenous fluid infusion. Which new assessment findings should the practical nurse identify as indicating an acute physiological complication that requires immediate intervention? Select all that apply.

  1. Production of pink, frothy sputumAnswer
  2. Oxygen saturation of 88% on room airAnswer
  3. New onset of crackles in the bilateral lung basesAnswer
  4. D
    Client reports a dull ache in the lower back rated 3 out of 10
  5. E
    Trace pitting edema in the ankles that is unchanged from admission

Answer

The findings requiring immediate intervention are the production of pink, frothy sputum, an oxygen saturation of 88% on room air, and new onset of crackles in the bilateral lung bases.
These assessment findings indicate the development of acute pulmonary edema, a life-threatening complication of fluid volume overload. Pink, frothy sputum, decreased oxygen saturation, and new lung crackles all signify acute respiratory failure and require immediate medical intervention to protect the client's airway and breathing.

Step-by-Step Solution

1
Identify the client's risk factors based on their medical history and current treatment.
The client has heart failure and is receiving intravenous fluids, placing them at high risk for fluid volume overload and acute pulmonary edema.
Understanding the clinical context helps anticipate potential life-threatening complications.
2
Evaluate each assessment finding using the Airway, Breathing, and Circulation (ABC) prioritization framework.
Sputum production, low oxygen saturation, and lung crackles indicate compromised airway and breathing.
ABCs must always be prioritized over chronic baseline findings or mild discomfort.

Key Concept

Recognizing Acute Pulmonary Edema and Prioritizing ABCs
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Topics

Physiological Adaptation

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