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?
1Encourage oral fluid intake to help loosen secretions.
2Apply oxygen and place the client in high Fowler position.✓ Correct answer
3Measure the client's daily weight to assess fluid retention.
4Teach the client about sodium restriction to manage heart failure.
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.
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 Practice GuideFor Acute pulmonary edema, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
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.