A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action?
a. Place the client in a high Fowler's posi-tion.
b. Perform nasotracheal suctioning of the client.
c. Auscultate the client's heart and lung sounds.
d. Place the client on a 1000 mL fluid re-striction.
A
Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suc-tioning is not needed.
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