A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, extreme anxiety, and a cough producing pink, frothy sputum. The nurse suspects acute pulmonary edema. In what order should the nurse perform the following actions? (Arrange the actions in the correct sequence from first to last)
- 1Position the client in a high-Fowler's position.
- 2Administer high-flow oxygen via a face mask.
- 3Assess vital signs and auscultate lung sounds.
- 4Administer prescribed intravenous furosemide.
- 5Document the clinical findings and response to interventions.
Answer
The correct sequence is: Position the client in a high-Fowler's position, Administer high-flow oxygen via a face mask, Assess vital signs and auscultate lung sounds, Administer prescribed intravenous furosemide, and finally, Document the clinical findings and response to interventions.
In an acute respiratory crisis such as pulmonary edema, the nurse must prioritize immediate, non-pharmacological life-saving actions. Positioning the client upright is the fastest intervention to improve breathing mechanics and reduce preload. This is immediately followed by oxygen administration to correct hypoxia. Once the airway and breathing are mechanically supported, the nurse must obtain baseline vital signs to ensure the client's blood pressure can tolerate the subsequent administration of intravenous loop diuretics. Finally, after the client is stabilized and interventions are implemented, the nurse documents the entire event.
Step-by-Step Solution
Key Concept
Prioritization of acute pulmonary edema management follows the ABCs (Airway, Breathing, Circulation) and the nursing process, moving from immediate physical interventions to pharmacological treatments and concluding with documentation.