The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen
What is the priority intervention of the nurse?
a.
Administer the ordered intravenous diuretic.
b.
Prepare for insertion of a chest tube.
c.
Suction secretions from the patient's respiratory tract.
d.
Have the patient use the ordered incentive spirometer.
ANS: A
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient's symptoms.
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