Final answer:
The nurse should first assess the blood pressure of a stable patient with acute decompensated heart failure who becomes dyspneic. This is essential to determine if there is a significant and immediate concern, like cardiogenic shock, that requires urgent attention.
Step-by-step explanation:
If a stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic, the nurse should first assess the patient's blood pressure. This initial assessment is crucial as a significant change in blood pressure could be indicative of cardiogenic shock or other emergent issues that need immediate attention. It is also possible that the patient's heart rhythm may need to be assessed following their blood pressure, but the blood pressure should be the priority.
For example, in the scenario of a patient arriving in the emergency department with a blood pressure of 70/45, confused and complaining of thirst, these symptoms could suggest circulatory shock. Similarly, a patient with a productive cough, dyspnea, fever, and low pulse-oximetry level could be experiencing an infection such as pneumonia, which can worsen cardiac stress in patients with ADHF. Blood pressure assessment can provide critical data that inform the urgency and direction of subsequent interventions.