During morning rounds, the nurse assesses a client recovering from an anterior wall myocardial infarction sustained two days prior. The client suddenly expresses intense anxiety and a feeling of suffocation. Auscultation reveals bilateral basilar crackles, and the client's skin is cool and diaphoretic.
The most recent clinical parameters are as follows:
| Parameter | Value |
|---|---|
| Blood Pressure | mm Hg |
| Heart Rate | beats/min |
| Respiratory Rate | breaths/min |
| pH | |
| mm Hg | |
| mm Hg | |
| mEq/L |
Which of the following is the highest priority nursing intervention?
- Elevate the head of the bed and apply supplemental oxygen.Cevap
- BInitiate a rapid intravenous bolus of 0.9% sodium chloride.
- CCoach the client to perform slow, pursed-lip breathing.
- DObtain a stat 12-lead electrocardiogram.
Cevap
The correct response is to elevate the head of the bed and apply supplemental oxygen.
The client is experiencing acute pulmonary edema and early cardiogenic shock, as evidenced by the anterior myocardial infarction history, basilar crackles, narrow pulse pressure, and severe hypoxemia. The immediate priority is to support the ABCs (Airway, Breathing, Circulation). Elevating the head of the bed decreases venous return (preload) to the failing heart and maximizes lung expansion, while supplemental oxygen directly treats the life-threatening hypoxemia.
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Anahtar Kavram
Prioritization of care in cardiogenic shock and acute pulmonary edema requires immediate stabilization of airway and breathing through upright positioning and supplemental oxygen.