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Zorluk: ZorPhysiological Adaptation

While rounding on a medical-surgical unit, a nurse assesses a client admitted with chronic heart failure. The client suddenly exhibits profound respiratory distress, orthopnea, and severe anxiety. Assessment reveals an oxygen saturation of 82% on room air, diffuse bilateral crackles, and the expectoration of pink, frothy sputum. Arrange the following collaborative and independent nursing actions in the correct order of priority. All options must be used.

  1. 1Assist the client into a high Fowler's position with their legs dangling over the edge of the bed.
  2. 2Deliver 100% oxygen via a non-rebreather device to address hypoxemia.
  3. 3Obtain a baseline blood pressure measurement and initiate continuous electrocardiogram monitoring.
  4. 4Inject the prescribed rapid-acting loop diuretic intravenously.
  5. 5Place an indwelling urinary catheter to strictly monitor diuresis.

Cevap

The correct sequence of actions is: position the client upright with legs dangling, deliver high-flow oxygen, assess blood pressure and cardiac rhythm, inject the intravenous loop diuretic, and finally, place the indwelling urinary catheter.
This sequence adheres to the nursing process and the ABC (Airway, Breathing, Circulation) priority framework for acute decompensation. Immediate physical positioning facilitates lung expansion and reduces preload. Oxygenation directly treats the resulting severe hypoxemia. Hemodynamic assessment must precede the administration of potent preload-reducing medications to ensure adequate organ perfusion. Finally, catheter placement serves as the evaluative measure for the diuretic therapy, making it the final action in this emergency sequence.

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1
Assist the client into a high Fowler's position with their legs dangling over the edge of the bed.
Decreases venous return to the heart and allows for maximum lung expansion.
Airway and breathing mechanics take immediate precedence. This action requires only seconds to perform and rapidly shifts fluid away from the central circulation.
2
Deliver 100% oxygen via a non-rebreather device to address hypoxemia.
Increases alveolar oxygen tension and forces oxygen across the fluid barrier in the lungs.
The client's oxygen saturation of 82% and pink, frothy sputum indicate acute pulmonary edema with severe gas exchange impairment. Immediate oxygenation is vital for survival.
3
Obtain a baseline blood pressure measurement and initiate continuous electrocardiogram monitoring.
Establishes a hemodynamic baseline and screens for life-threatening dysrhythmias.
Before administering medications that drastically reduce circulating volume and preload, the nurse must verify the client is not experiencing profound hypotension or cardiovascular collapse.
4
Inject the prescribed rapid-acting loop diuretic intravenously.
Removes excess fluid volume and relieves acute pulmonary congestion.
Diuretics are the definitive pharmacological treatment for acute cardiogenic pulmonary edema, acting to rapidly offload fluid from the lungs.
5
Place an indwelling urinary catheter to strictly monitor diuresis.
Facilitates accurate measurement of massive urine output and prevents bladder injury.
Intravenous loop diuretics cause rapid and substantial urine production. A catheter evaluates the medication's effectiveness, but it is an invasive procedure that ranks lowest in immediate life-saving priority.

Anahtar Kavram

In acute pulmonary edema, immediate nursing priorities follow the ABC framework: optimize breathing mechanics via positioning, deliver high-concentration oxygen, assess circulation (blood pressure), and finally intervene with pharmacological fluid offloading.
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Physiological Adaptation

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