A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority?
a. Administer digoxin.
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position.
D
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung conges-tion immediately before other measures can be carried out. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid.
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