Question

Which assessment finding in a patient admitted with acute decompensated heart failure

(ADHF) requires the most immediate action by the nurse?
a. O2 saturation of 88%
b. Weight gain of 1 kg (2.2 lb)
c. Heart rate of 106 beats/min
d. Urine output of 50 mL over 2 hours

Answer 1

The most immediate action by the nurse in a patient admitted with acute decompensated heart failure (ADHF) would be required for the assessment finding of a low O2 saturation of 88%.

Step-by-step explanation:

In a patient admitted with acute decompensated heart failure (ADHF), the most immediate action by the nurse would be required for the assessment finding of a low O2 saturation of 88%. ADHF is a serious condition in which the heart is unable to pump enough blood to meet the body's needs. A low O2 saturation indicates inadequate oxygen supply to the tissues and requires immediate intervention, such as administering supplemental oxygen or initiating respiratory support.