# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620037&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

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.

Immediate nursing actions

Place the client in high-Fowler's position

Apply oxygen and titrate to the prescribed saturation target

Encourage oral fluid intake of 3 L/day

Begin detailed sodium-restriction teaching now

Prescribed medications to administer

Intravenous furosemide

Nitroglycerin for the hypertensive pulmonary edema

The routine oral metoprolol dose before stabilization

A rapid 0.9% sodium chloride bolus

## Explanation

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.

## In-depth explanation

Quick answer
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.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

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.

## Key concepts

- **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.

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