0800: Upon assessment, the client is visibly anxious and struggling to breathe, with pink frothy sputum noted during coughing.The client is experiencing sudden shortness of breath and chest tightness. Physical examination reveals bilateral crackles in all lung fields, jugular venous distension (JVD), and peripheral cyanosis. An ECG shows sinus tachycardia with no ischemic changes, and a chest X-ray reveals pulmonary vascular congestion. The client reports a history of chronic heart failure.
Vital Signs
Heart Rate (HR) 118 bpm
Blood Pressure (BP) 182/98 mmHg
Respiratory Rate (RR) 32 breaths/min
Oxygen Saturation (SpO₂) 82%
Temperature 37.9°C (100.2F)
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action to take: Administer high-flow oxygen via a non-rebreather mask. | Initiate a fluid bolus of 0.9% normal saline | Administer sublingual nitroglycerin as prescribed. | Administer IV morphine sulfate as prescribed. | Position the client in the Trendelenburg position
Most likely experiencing: Chronic obstructive pulmonary disease (COPD) exacerbation | Acute respiratory distress syndrome (ARDS) | Cardiac tamponade | pulmonary edema
Parameter to Monitor: Blood pressure | Oxygen saturation | Respiratory rate | Urine output | Temperature
Action to take: Administer high-flow oxygen via a non-rebreather mask. | Initiate a fluid bolus of 0.9% normal saline | Administer sublingual nitroglycerin as prescribed. | Administer IV morphine sulfate as prescribed. | Position the client in the Trendelenburg position
Parameter to Monitor: Blood pressure | Oxygen saturation | Respiratory rate | Urine output | Temperature
Sign in to reveal the correct answer & rationale
A free account unlocks answers for the preview questions in every exam. A pass unlocks all of them.