Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?
a. Oxygen saturation of 88%
b. Weight gain of 1 kg (2.2 lb)
c. Heart rate of 106 beats/minute
d. Urine output of 50 mL over 2 hours
ANS: A
A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.
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