A client with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which of the following actions should the nurse take first?
A)Palpate the abdomen.
B)Assess the orientation.
C)Check the capillary refill.
D)Auscultate the lung sounds.

Question

Quizplus · Accepted Answer

This client'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 or respiratory arrest. The other assessments will provide useful data about the client's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

A Client with a History of Chronic Heart Failure Is