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Difficulty: MediumReduction of Risk Potential

A client with a history of heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride at 125 mL/hr. During a reassessment, the nurse notes new-onset bibasilar crackles, a respiratory rate of 28 breaths/min, and an oxygen saturation of 88% on room air. The latest arterial blood gas (ABG) results are pH 7.30, PaCO2PaCO_2 52 mm Hg, PaO2PaO_2 55 mm Hg, and HCO3−HCO_3^- 25 mEq/L. Which action should the nurse take first to reduce the risk of further physiological deterioration?

  1. A
    Position the client supine with the lower extremities elevated to maximize systemic perfusion.
  2. B
    Direct the unlicensed assistive personnel to obtain and report the client's vital signs every 15 minutes.
  3. Elevate the head of the bed to a high-Fowler's position and initiate prescribed oxygen therapy.Answer
  4. D
    Encourage the client to breathe slowly into a paper bag to help correct the current acid-base abnormality.

Answer

The priority action is to elevate the head of the bed to a high-Fowler's position and initiate prescribed oxygen therapy.
Elevating the head of the bed to a high-Fowler's position uses gravity to pull the diaphragm downward, maximizing lung expansion. Importantly, it also decreases venous return (preload) to the right side of the heart, which is crucial for reducing pulmonary congestion in a client experiencing heart failure exacerbation. Concurrently administering oxygen directly addresses the severe hypoxemia (PaO2PaO_2 55 mm Hg) indicated by the ABG results.

Step-by-Step Solution

1
Analyze the clinical presentation and laboratory data.
The client shows signs of fluid volume overload (crackles) leading to acute respiratory failure, as indicated by uncompensated respiratory acidosis (pH 7.30, PaCO2PaCO_2 52 mm Hg) and hypoxemia (PaO2PaO_2 55 mm Hg).
Identifying the underlying physiological problem is essential for selecting the correct risk-reduction intervention.
2
Determine the immediate priority to reduce the risk of deterioration.
The primary risk is worsening hypoxia and complete respiratory collapse.
According to the ABCs (Airway, Breathing, Circulation) framework, optimizing oxygenation and ventilation takes absolute precedence.
3
Select the most appropriate nursing intervention.
Placing the client in a high-Fowler's position and providing oxygen directly addresses the immediate physiological threats.
High-Fowler's position uses gravity to promote maximum lung expansion and decrease venous return (preload) to the heart, while supplemental oxygen treats the life-threatening hypoxemia.

Key Concept

Prioritization of care for acute pulmonary edema involves immediate positioning to optimize lung expansion and reduce cardiac preload, alongside supplemental oxygenation to correct hypoxemia.
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Reduction of Risk Potential

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