A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, becomes extremely restless, and expectorates pink, frothy sputum. Arrange the following nursing actions in the correct sequence of priority from first to last.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Apply high-flow oxygen via a non-rebreather mask.
- 3Administer the prescribed intravenous loop diuretic.
- 4Insert a prescribed indwelling urinary catheter.
Answer
The correct priority sequence is to elevate the head of the bed first, apply high-flow oxygen second, administer the intravenous diuretic third, and insert the urinary catheter last.
In the setting of acute pulmonary edema, the client is experiencing acute respiratory distress due to fluid shifting rapidly into the alveoli. According to airway-breathing-circulation (ABC) prioritization, the most immediate action that can be taken without waiting for equipment is to elevate the head of the bed. This decreases venous return (preload) and allows the lungs to expand fully. Next, high-flow oxygen must be applied to directly treat the resulting severe hypoxia. Once the client's respiratory status is immediately supported, the nurse should administer the prescribed intravenous loop diuretic to eliminate the excess fluid causing the edema. Finally, inserting an indwelling urinary catheter allows for accurate measurement of the profound diuresis that will follow the diuretic administration, enabling precise evaluation of the treatment's effectiveness.
Step-by-Step Solution
Key Concept
Prioritization in Acute Pulmonary Edema