A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to

Question

Quizplus · Accepted Answer

When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. 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 should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.

A Patient with a History of Chronic Heart Failure Is