An emergency department nurse is caring for an older adult client who presents with profound lethargy and confusion. The client has a known medical history of heart failure with a severely reduced ejection fraction. The client's family reports a three-day history of dysuria, chills, and fever prior to admission.
Current vital signs:
- Blood pressure: 76/48 mm Hg (MAP 57 mm Hg)
- Heart rate: 134 bpm
- Respiratory rate: 32 breaths/min
- Temperature: 39.2 °C (102.6 °F)
- Oxygen saturation: 88% on 4 L/min via nasal cannula
Physical assessment reveals prominent jugular venous distention at a 45-degree angle, cool and mottled extremities, and coarse crackles auscultated bilaterally up to the mid-lung fields.
| Parameter | Value |
|---|---|
| pH | 7.25 |
| PaCO2 | 28 mm Hg |
| PaO2 | 58 mm Hg |
| HCO3- | 12 mEq/L |
| Lactate | 6.1 mmol/L |
Based on the client's clinical presentation and laboratory data, which of the following prescribed interventions is the highest priority for the nurse to implement?
- Initiate a prescribed norepinephrine infusion to restore mean arterial pressure and tissue perfusion.Cevap
- BAdminister a prescribed 500 mL intravenous fluid bolus to increase circulatory volume and clear the lactate.
- CPrepare for immediate endotracheal intubation and mechanical ventilation to resolve the respiratory acidosis.
- DAdminister a prescribed dose of intravenous furosemide to reduce preload and clear the pulmonary edema.