A 55-year-old patient with chronic heart failure is admitted to the medical unit with acute exacerbation. The patient presents with severe dyspnea, bilateral lower extremity edema, and jugular venous distension. Vital signs: BP 160/95 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. Laboratory results show BNP 2,400 pg/mL (normal <100 pg/mL). What is the nurse's priority assessment?

• 1 Monitor blood pressure and heart rate every 15 minutes.
• 2 Assess for signs of digitalis toxicity.
• 3 Evaluate peripheral pulse strength and capillary refill.
• 4 Auscultate lung sounds and assess respiratory effort. ✓ 정답

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