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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client on a medical-surgical unit who suddenly develops severe dyspnea, a respiratory rate of 34/min, and produces pink, frothy sputum. Crackles are auscultated throughout both lung fields. Arrange the following nursing actions in the priority order they should be performed.

  1. 1Position the client upright with legs dangling over the edge of the bed.
  2. 2Apply high-flow oxygen via a non-rebreather face mask.
  3. 3Administer the prescribed intravenous furosemide.
  4. 4Insert an indwelling urinary catheter.

Answer

The correct sequence for managing acute pulmonary edema is to first position the client upright with legs dangling, then apply high-flow oxygen, followed by administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In cases of acute pulmonary edema, nursing priorities follow the airway, breathing, and circulation (ABC) framework combined with hemodynamic principles. Positioning the client upright with legs dangling is the fastest way to reduce venous return (preload) and improve lung expansion. Oxygen is applied immediately after to treat severe hypoxemia. Intravenous diuretics are then given to actively remove excess fluid. Finally, a urinary catheter is placed to monitor the therapeutic response to the diuretic.

Step-by-Step Solution

1
Position the client upright with legs dangling over the edge of the bed.
Immediate reduction in venous return and improvement in lung expansion.
Airway and Breathing take priority. Positioning uses gravity to reduce preload, instantly decreasing pulmonary congestion without needing to wait for equipment or medication.
2
Apply high-flow oxygen via a non-rebreather face mask.
Increased alveolar oxygen concentration.
Pink, frothy sputum and profound tachypnea indicate severe pulmonary edema and hypoxemia. Supplying oxygen maximizes gas exchange in the unaffected alveoli.
3
Administer the prescribed intravenous furosemide.
Initiation of rapid diuresis and vasodilation.
Once immediate cardiopulmonary support is established, pharmacological intervention is required to actively pull fluid out of the pulmonary circulation by reducing overall vascular volume.
4
Insert an indwelling urinary catheter.
Continuous monitoring of urine output.
This is a necessary monitoring step to evaluate the therapeutic effect of the loop diuretic, but it must not delay the life-saving interventions in steps 1-3.

Key Concept

Prioritization of interventions in acute pulmonary edema (ABC approach combined with preload reduction).
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Topics

Physiological Adaptation

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