A nurse is assessing a client with a history of heart failure who suddenly develops severe dyspnea, a respiratory rate of 34 breaths/min, and pink, frothy sputum. Arrange the following nursing actions in the correct sequence of priority.
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Apply high-flow supplemental oxygen via a non-rebreather mask.
- 3Obtain a complete set of vital signs and oxygen saturation.
- 4Administer the prescribed intravenous rapid-acting loop diuretic.
- 5Initiate strict measurement of hourly urine output.
Cevap
The correct priority sequence is to first elevate the head of the bed, then apply oxygen, obtain vital signs, administer the intravenous diuretic, and finally monitor hourly urine output.
In cases of rapid respiratory decompensation such as acute pulmonary edema, nursing prioritization follows the ABCs (Airway, Breathing, Circulation) framework. Immediate physical interventions that support breathing (positioning and oxygen) take absolute priority. Once the airway and breathing are supported, the nurse must assess the client's hemodynamic baseline (circulation) before administering medications that drastically alter fluid volume. Evaluation of the pharmacological intervention follows as the final step.
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Anahtar Kavram
Prioritization of nursing interventions for acute pulmonary edema.