# A client with heart failure develops severe orthopnea, diffuse crackles, pink frothy sputum, and an oxygen saturation of 84%. Complete the priority response. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=396092&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A client with heart failure develops severe orthopnea, diffuse crackles, pink frothy sputum, and an oxygen saturation of 84%. Complete the priority response. The nurse should recognize ::선택::stable chronic heart failure without congestionisolated anxiety with normal gas exchangeacute cardiogenic pulmonary edema with hypoxemic respiratory distressexpected positional discomfort, first ::선택::sit the client upright, apply prescribed oxygen, begin continuous assessment, and activate urgent helpplace the client flat with the legs elevatedgive a large oral fluid bolusdelay reassessment until after routine morning care, and then ::선택::encourage unrestricted ambulation despite severe hypoxemiawithhold monitoring after the oxygen saturation improves oncefocus only on sleep-hygiene teachingadminister the prescribed IV loop diuretic, prepare ventilatory support if needed, and monitor urine output, renal function, and electrolytes. ## 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. ## In-depth explanation 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 ## Clinical scenario 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. ## Key concepts - **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. ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. 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