A nurse is caring for a client who has developed cardiogenic shock after developing heart failure. The nurse enters the client's room and finds that the client has an altered level of consciousness, jugular venous distention, and a heart rate of 122 bpm. Which of the following interventions would be a priority for the nurse to perform first?
a. Administer prn anti-inflammatory drugs as ordered
b. Check the client's peripheral pulses, including pedal and posterior tibial pulses
c. Conduct laboratory studies to check the client's PT and PTT levels
d. Administer prn diuretic medications as ordered
d. Administer prn diuretic medications as ordered
rationale: "Administer prn diuretic medications as ordered" is correct. A client in heart failure who has developed cardiogenic shock will often demonstrate evidence of excess fluid in the cardiovascular system, including distended neck veins, shortness of breath, edema, and tachycardia. All of these symptoms together can cause altered consciousness and increase the workload of the heart, and the nurse's initial response should be to administer medications that will decrease the work of the heart and manage fluid levels in the cardiovascular system. Diuretic medications work to reduce intravascular volume so that excess fluid can be released through the urine.
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