Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
Vital Signs (0700 hrs): Temperature: 36.7°C (98.0°F), Pulse rate: 114/min, Respiratory rate: 30/min, Blood pressure: 92/66 mm Hg, Oxygen saturation: 90%. Medication Administration Record (0700 hrs): Furosemide 40 mg IV every 6 hr. Administered at 0600. Digoxin 250 mcg IV now. Administered at 0600. Physical Examination Results (0700 hrs): Jugular vein distention noted. Lower extremity edema 2+ bilaterally. Extremities cool with decreased skin pigmentation. Peripheral pulses weak bilaterally. Lung sounds with wheezing noted throughout. Diagnostic Results (0700 hrs): Chest X-ray: Cardiomegaly noted. Echocardiogram: Left ventricular hypertrophy, mitral valve stenosis. BNP: 1200 pg/mL.Based on the information provided, what is the most appropriate initial nursing action?
Correct answer
D
Rationale
The most appropriate initial nursing action is to reposition the client to a high Fowler's position (choice D). This position helps improve oxygenation by maximizing lung expansion. It facilitates better airflow and oxygen exchange in the lungs, making it crucial for clients experiencing respiratory distress. Increasing the oxygen flow rate (choice A) can be done after repositioning the client. Administering an additional dose of furosemide (choice B) is not appropriate without further assessment. Notifying the healthcare provider (choice C) can be done after addressing the immediate need for improved oxygenation through repositioning.