A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
a. Assess the client's respiratory status.
b. Draw blood to assess the client's serum electrolytes.
c. Administer intravenous furosemide (Lasix).
d. Ask the client about current medications.
ANS: A
Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.
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