A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?
a. Auscultate the abdomen.
b. Check the capillary refill.
c. Auscultate the breath sounds.
d. Assess the level of orientation.
ANS: C
This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.
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