An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea. The nurse notes shallow rapid respirations and a cough that produces frothy sputum. Which is the priority nursing action?
a. Assess the urine output.
b. Elevate the head of the bed.
c. Encourage the patient to cough.
d. Maintain the IV rate.
ANS: B
Elevating the head of the bed is an appropriate action for signs and symptoms of pulmonary edema. Urine output is important to assess, but it is not the priority nursing action. Encouraging the patient to cough and take deep breaths is not the priority nursing action. The IV rate should be slowed immediately based on the signs and symptoms the patient is displaying.
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