While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which of the following actions should the nurse take first?
a. Place the patient in a high Fowler's position.
b. Provide a urinal and encourage the patient to void.
c. Provide oxygen at 2 L per nasal cannula.
d. Lay the patient flat in bed to listen to bowel sounds.
ANS: A
To facilitate ease in breathing, the head of the patient's bed should be in semi-Fowler's or high Fowler's position. These positions allow greater lung expansion and thus aid respiratory effort. Voiding will not relieve fluid overload in the absence of diuretic therapy. Oxygen is not necessary at this time, as the pulse oximeter reading is within normal limits. Laying the patient flat in bed may cause dyspnea.
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