A client with acute heart failure has severe dyspnea, orthopnea, bilateral crackles, oxygen saturation 88% on room air, and blood pressure 178/104 mm Hg. The nurse implements the prescribed plan for hypertensive pulmonary edema. For each group, select all responses that apply.

Positioning upright and applying prescribed oxygen address hypoxemia and work of breathing. In hypertensive pulmonary edema, prescribed IV furosemide reduces congestion and prescribed nitroglycerin reduces preload and blood pressure. A large oral-fluid intake or isotonic bolus can worsen congestion; diet teaching is deferred until stabilization, and routine oral beta-blocker administration is not the immediate treatment for this unstable presentation.

Use only the findings, timing, and orders stated in the scenario.

Apply the requested nursing decision to this client rather than relying on a broad disease label.

The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.

Address immediate threats first and reassess after intervention.

Choose only actions supported at this exact point in care.

• heart failure — heart failure is a key clinical concept for assessing and managing worsening heart failure.
• dyspnea — dyspnea is a key clinical concept for assessing and managing worsening heart failure.
• furosemide — furosemide is a key clinical concept for assessing and managing worsening heart failure.