Question

The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse?

Answer 1

When a patient with a diagnosis of congestive failure becomes anxious and tachypneic, the nurse should ensure safety, provide reassurance, check vital signs, provide supplemental oxygen if needed, and assess the cause of distress before proceeding.

Step-by-step explanation:

Best Action for a Patient with Congestive Failure Becoming Anxious and Tachypneic

When a patient with congestive failure becomes anxious and tachypneic during a procedure to obtain a pulmonary artery occlusion pressure, the best action for the nurse is to first ensure the patient's safety and address the immediate anxiety and respiratory distress. This can be done by:

• Stopping the procedure temporarily.
• Reassuring the patient and providing a calm and supportive environment.
• Assessing the patient's vital signs, including oxygen saturation, and providing supplemental oxygen if needed.
• Evaluating the cause of anxiety and tachypnea – is it due to discomfort, fear of the procedure, or a worsening of their condition?
• If necessary, notifying the physician and considering medication to relieve anxiety and improve respiratory function.

After the patient's condition is stabilized and they are comfortable, the nurse can then proceed with the measurement if it's deemed safe to continue.