Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue

Question

Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is to
A)
have medical supply department bring up suction equipment.
B)
apply oxygen via nasal cannula at 3 lpm.
C)
page the respiratory therapist to come give him a breathing treatment.
D)
call for emergency assistance utilizing hospital protocol.

Answer 1

Ans:
D

Feedback:

Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The patient needs the emergency responder team (including ICU nurses, physicians, respiratory therapist, etc.) to intervene. Applying O2 by mask will not increase his oxygen level fast enough, and he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course respiratory therapist will arrive with the emergency assistance team.