A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention?
a. Assess respiratory status.
b. Monitor electrolyte levels.
c. Administer intravenous fluids.
d. Insert a Foley catheter.
A
Assessment of respiratory and oxygenation status is the priority nursing intervention for the pre-vention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.
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