NCLEX-PN® ExaminationReduction of Risk PotentialHard
A client with a history of heart failure reports sudden shortness of breath, orthopnea, and cough producing pink, frothy sputum. The LPN notes crackles in the lung bases and an oxygen saturation of 88% on room air. Which is the priority nursing action?
- ANotify the registered nurse (RN) or healthcare provider.
- BElevate the head of the client's bed.
- CAdminister furosemide as prescribed.
- DApply oxygen via nasal cannula.
Show answer & explanationAnswer & explanation
Correct answer: D. Apply oxygen via nasal cannula.
The client's symptoms (shortness of breath, orthopnea, pink frothy sputum, crackles, SpO2 88%) are indicative of acute pulmonary edema, a life-threatening condition. The immediate priority is to improve oxygenation to prevent further hypoxemia. Applying oxygen is the most direct and rapid intervention to address the low oxygen saturation.
Why the other options are wrong
- A. Notifying the RN/provider is essential after initiating immediate life-saving interventions, as this is an emergent situation.
- B. Elevating the head of the bed helps with breathing but does not directly address the severe hypoxemia.
- C. Administering furosemide is important but will take time to work and is not the immediate priority over oxygenation.
Acute Pulmonary Edema
A medical emergency characterized by excessive fluid in the lungs, often caused by left-sided heart failure, leading to severe respiratory distress.
- Symptoms: severe dyspnea, orthopnea, pink frothy sputum, crackles, hypoxemia
- Interventions: elevate HOB, oxygen, diuretics, vasodilators (e.g., nitroglycerin), morphine
- Priority: improve oxygenation and reduce fluid overload
Memory trick: ABC: Airway, Breathing, Circulation – Always First!