The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first?

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The client being admitted for heart failure-related fluid overload is likely to have dyspnea (difficulty breathing), orthopnea (labored breathing in a supine position), and paroxysmal nocturnal dyspnea (waking suddenly with difficulty breathing). The assessment phase of the nursing process must come before intervention and should be prioritized using the ABCs: airway, breathing, and circulation. Therefore, the nurse should first assess the client's breath sounds (Option B). Rales or "crackles" may be auscultated in the lungs as a result of pulmonary congestion. (Option A) The client's current respiratory status (ie, breath sounds, oxygen saturation) must be evaluated prior to giving oxygen. Oxygen saturation should be assessed upon admission and every 4-6 hours based on hospital protocol; oxygen is subsequently administered based on client needs. (Option C) It is appropriate for this client to have continuous cardiac monitoring that can alert staff to life-threatening rhythms (eg, ventricular tachycardia) if they occur. However, the client's respiratory status should be assessed first. (Option D) This client will require IV administration of diuretics, such as furosemide, to reduce excess fluid volume and preload. A peripheral IV catheter should be placed, but assessment of the client's current status takes priority. Educational objective: The client with heart failure-related fluid overload usually has respiratory symptoms. Assessment of the client's breathing is the greatest priority. It should be performed before assessment of cardiac rhythm and interventions such as oxygen and placing an IV for diuretic administration.

The Nurse Is Admitting a Client with Heart Failure-Related Fluid