As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would
a. administer oxygen as ordered using a high-flow rebreather bag.
b. bring a tracheostomy set to the bedside.
c. monitor vital signs every 30 to 45 minutes until stable.
d. position the client's legs above heart level.
A
The nurse should monitor vital signs every 15 minutes initially until the client is stable and administer oxygen as ordered using a high-flow rebreather bag to maintain oxygenation (oxygen saturation above 90%). Mechanical ventilation and intubation equipment should be nearby. To reduce preload, the client should be positioned with the legs dependent. Raising edematous legs increases venous return and will stress the overtaxed left ventricle.
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