A client with heart failure develops severe orthopnea, diffuse crackles, pink frothy sputum, and an oxygen saturation of 84%. Complete the priority response.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Severe orthopnea, diffuse crackles, pink frothy sputum, and hypoxemia indicate acute pulmonary edema. Sit the client upright, support oxygenation, and escalate immediately. Administer prescribed IV loop diuretic, prepare noninvasive ventilation if needed, and monitor vital signs, urine output, renal function, and electrolytes.
Quick answer Recognize acute cardiogenic pulmonary edema, position the client upright, support oxygenation, activate urgent help, and begin prescribed decongestive therapy with close response monitoring.
Why this is correct Pink frothy sputum, diffuse crackles, severe orthopnea, and an oxygen saturation of 84% indicate pulmonary congestion with respiratory failure. Upright positioning and oxygen address immediate breathing needs while the team treats fluid overload and considers ventilatory support.
Easy analogy or mental picture Think of fluid flooding the lung's gas-exchange surface. Raise the chest, support oxygen movement, and remove excess fluid while watching whether breathing improves.
Memory hook Wet lungs plus severe hypoxemia: upright, oxygen, urgent help, diurese, reassess.
NCLEX decision rule Stabilize airway and breathing while treating the cause. IV loop diuretics are recommended for hospitalized heart-failure congestion; monitor symptoms, oxygenation, blood pressure, urine output, renal function, and electrolytes. Prepare noninvasive ventilation when respiratory distress persists and it is not contraindicated.
Why the other choices are wrong Trendelenburg or lying flat worsens orthopnea. A large fluid bolus aggravates congestion, and delaying assessment for routine care ignores life-threatening hypoxemia.
Source
12022 AHA/ACC/HFSA Heart Failure Guideline
2ESC Acute Cardiovascular Care Toolkit 2025: Acute Heart Failure
32026 NCLEX-RN Test Plan
The nurse recognizes acute pulmonary edema with hypoxemic respiratory distress. Emergency-response resources, continuous monitoring, prescribed oxygen and IV diuretic therapy, and noninvasive ventilation are available according to the client's blood pressure and response.
Acute cardiogenic pulmonary edema — Rapid accumulation of fluid in the lungs caused by elevated cardiac filling pressures, producing severe dyspnea and hypoxemia.
Orthopnea — Shortness of breath that worsens when lying flat and improves when the upper body is elevated.
Noninvasive ventilation — Positive-pressure breathing support delivered through a mask, such as CPAP or bilevel positive airway pressure.