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Difficulty: MediumPhysiological Adaptation

While completing a shift assessment on a telemetry unit, a nurse evaluates a client who experienced an acute myocardial infarction 48 hours ago. The client exhibits sudden, severe dyspnea, expectorates pink, frothy sputum, and has coarse crackles auscultated throughout both lung fields. Which of the following is the priority nursing action?

  1. Apply prescribed supplemental oxygen via a non-rebreather mask.Answer
  2. B
    Obtain a stat 12-lead electrocardiogram to assess for further ischemia.
  3. C
    Increase the rate of the continuous intravenous maintenance fluids.
  4. D
    Position the client flat in bed with the lower extremities elevated.

Answer

Apply prescribed supplemental oxygen via a non-rebreather mask.
The client's symptoms (severe dyspnea, coarse crackles, and pink, frothy sputum) are classic signs of acute pulmonary edema, a life-threatening complication of myocardial infarction resulting from left-sided heart failure. Using the ABC (Airway, Breathing, Circulation) prioritization framework, addressing the severe impairment in oxygenation is the most critical immediate action. Administering supplemental oxygen directly treats the severe hypoxemia.

Step-by-Step Solution

1
Analyze the clinical findings to identify the underlying complication.
The combination of sudden severe dyspnea, pink and frothy sputum, and coarse crackles indicates acute pulmonary edema, a medical emergency resulting from left-sided heart failure following a myocardial infarction.
Recognizing the life-threatening complication is essential for determining the appropriate emergency interventions.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The client is actively experiencing a severe impairment in gas exchange and breathing, making respiratory support the absolute highest priority.
Airway and breathing must be stabilized before addressing circulation, running diagnostic tests, or addressing other concerns.
3
Evaluate the given options to select the most appropriate initial intervention.
Applying supplemental oxygen directly addresses the breathing compromise. Interventions like positioning the client flat or increasing IV fluids will exacerbate fluid overload.
Selecting the correct action ensures immediate patient safety and avoids interventions that could cause further physiological harm.

Key Concept

Management of acute pulmonary edema and application of the ABC framework.
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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