A client on the cardiac step-down unit suddenly develops severe dyspnea, audible wheezing, and expectorates pink, frothy sputum. The vital signs monitor shows an oxygen saturation of 84% on room air and a heart rate of 122 beats/min. Arrange the following nursing interventions in the most appropriate sequential order from first to last.
- 1Position the client upright in a high-Fowler's position with the legs dangling over the bedside.
- 2Provide supplementary oxygen utilizing a non-rebreather mask.
- 3Administer the prescribed intravenous dose of a loop diuretic.
- 4Place an indwelling urinary retention catheter.
Answer
First, position the client upright with legs dangling. Second, provide supplementary oxygen. Third, administer the intravenous loop diuretic. Finally, place an indwelling urinary catheter.
The correct sequence relies on the ABCs and prioritization principles for acute physiological decompensation. In acute pulmonary edema, positional changes (high-Fowler's with legs dangling) represent the fastest, most effective non-pharmacological method to reduce preload and improve lung expansion. This is immediately followed by oxygen therapy to directly address the 84% oxygen saturation. Once basic airway and breathing mechanics are supported, pharmacological reduction of the fluid volume is initiated. Lastly, placing a catheter allows the nurse to monitor the therapeutic response to the diuretic.
Step-by-Step Solution
Key Concept
Prioritization in Acute Pulmonary Edema