A client is in the hospital for heart failure and respiratory management. During a focused assessment, the nurse notes that the client coughs frothy pink sputum. The immediate intervention by the nurse would be to:
1. Place the client in a high Fowler's position.
2. Ask the laboratory to obtain an arterial blood gas.
3. Notify the physician.
4. Stop the administration of oxygen.
Answer: 3
1. The client with right-sided failure should already be in the high Fowler's position.
2. The nurse requests a blood gas after the physician examines the client.
3. The physician should be notified immediately, as the sputum indicates the client is accumulating fluid in the lungs.
4. If the client is on oxygen, the nurse does not stop it.
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