A nurse is caring for a client admitted with an exacerbation of heart failure. The client suddenly develops severe dyspnea, extreme anxiety, and begins coughing up pink, frothy sputum. Arrange the following nursing actions in the priority order they should be performed.
- 1Place the client in a high Fowler's position with legs dependent.
- 2Administer high-flow oxygen.
- 3Obtain vital signs and auscultate lung sounds.
- 4Administer the prescribed intravenous furosemide.
- 5Insert an indwelling urinary catheter.
Answer
The correct priority sequence is to first place the client in a high Fowler's position, followed by administering high-flow oxygen, obtaining vital signs, administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In acute pulmonary edema, the absolute priority is airway and breathing. Placing the client in a high Fowler's position immediately reduces venous return and eases breathing. Oxygen is applied next to treat hypoxia. Once ABCs are stabilized, baseline vital signs must be taken to safely administer medications. Intravenous furosemide is then given to pull fluid from the lungs, followed by the insertion of a urinary catheter to closely monitor the diuresis.
Step-by-Step Solution
Key Concept
Prioritization of care in acute pulmonary edema focuses on the ABCs: optimizing breathing mechanics and oxygenation before proceeding to assessment and pharmacological interventions.