Which assessment finding in a client admitted with chronic heart failure requires the most rapid action by the nurse?
A)Oxygen saturation of 88%
B)Weight gain of 1 kg
C)Apical pulse rate of 106 beats/minute
D)Urine output of 50 mL over 2 hours

Question

Quizplus · Accepted Answer

In a person with HF, oxygen saturation of the blood may be reduced because the blood is not adequately oxygenated in the lungs. Administration of oxygen, if the O2 saturation is less than 90%, can improve tissue oxygenation. Thus, appropriate use of oxygen therapy helps relieve dyspnea and fatigue. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

Which Assessment Finding in a Client Admitted with Chronic Heart