Final answer:
The nurse's priority action for a client with heart failure experiencing acute shortness of breath is to place the client in a high Fowler's position to facilitate easier breathing. Subsequent actions include auscultating heart and lung sounds and considering fluid restriction as part of ongoing treatment based on the client's condition.
Step-by-step explanation:
Priority Action for Acute Shortness of Breath in Heart Failure
When caring for a client with heart failure who is experiencing acute shortness of breath, the nurse's priority action should be to assist in improving the client's oxygenation and comfort. The appropriate initial step would be a. Place the client in a high Fowler's position. This position, which involves sitting the client upright at a 60-90 degree angle, facilitates easier breathing by reducing pressure on the diaphragm, allowing for maximum expansion of the chest and improving lung ventilation. While subsequent actions might include performing nasotracheal suctioning, auscultation of heart and lung sounds, and fluid restriction, these are not the immediate priority.
Auscultation of heart and lung sounds might follow initial interventions to evaluate the effectiveness of the actions taken and to gather more information on the client's condition. This can help in diagnosing specific issues like fluid accumulation in the lungs or detecting abnormal heart rhythms common in heart failure patients.
Fluid restriction is a management strategy in heart failure that may be considered later in the treatment plan, particularly if the client is in fluid overload. However, it is not a first-line immediate action for acute shortness of breath. Clinicians often use diagnostic tools such as a pulse oximeter to monitor oxygen saturation, or conduct imaging like a chest radiograph for further investigation if needed.