# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397146&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

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?

## Option

1. Obtain a daily weight.
2. Apply oxygen and place the client in high Fowler position. **✔ Correct answer**
3. Encourage oral fluids to thin secretions.
4. Teach sodium restriction for long-term control.

**Correct answer: 2**

## 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.

## In-depth explanation

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 scenario

Clinical Practice Guide
For Acute pulmonary edema, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **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.

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