A client with heart failure suddenly becomes anxious and has… | MyMerci
Medical EmergenciesPA
Question
A client with heart failure suddenly becomes anxious and has crackles, frothy sputum, and oxygen saturation of 84%. Which action should the nurse take first?
1Obtain a daily weight.
2Apply oxygen and place the client in high Fowler position.✓ Correct answer
3Encourage oral fluids to thin secretions.
4Teach sodium restriction for long-term control.
Explanation
Acute pulmonary edema threatens oxygenation, so the first action is to improve ventilation and oxygen delivery while positioning the client upright. Daily weight and sodium teaching are important for chronic management but not the priority during acute respiratory compromise. Oral fluids may worsen overload.
In-depth explanation
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Acute pulmonary edema.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Acute pulmonary edema, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Pulmonary Edema — Fluid accumulation in the lungs that impairs gas exchange.
High Fowler Position — An upright position that can improve chest expansion and breathing.
Oxygen Saturation — A measure of hemoglobin oxygen binding in peripheral blood.