Question

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Prioritize the nursing interventions chronologically.

A) Administer prescribed diuretics.
B) Elevate the head of the bed.
C) Administer oxygen therapy.
D) Monitor vital signs.
E) Assess lung sounds.
F) Administer prescribed medications (e.g., nitroglycerin).
G) Restrict fluid intake.
H) Provide emotional support to the client and family.
I) Prepare for possible intubation and mechanical ventilation if respiratory distress persists.

Answer 1

The nursing interventions for a client with pulmonary edema should be elevated head of the bed, assess lung sounds, administer oxygen, monitor vitals, administer diuretics and medications like nitroglycerin, restrict fluids, provide emotional support, and prepare for ventilation if needed.

Step-by-step explanation:

When caring for a client with pulmonary edema whose respiratory status is declining, the priority nursing interventions should be chronological to ensure rapid stabilization of the client's condition. The following interventions are generally prioritized as follows:

1. Elevate the head of the bed to help improve breathing and gas exchange.
2. Assess lung sounds to determine the presence of crackles or wheezes associated with fluid accumulation.
3. Administer oxygen therapy to increase the level of oxygen in the blood.
4. Monitor vital signs to detect any changes in the heart rate, blood pressure, respiratory rate, and oxygen saturation.
5. Administer prescribed diuretics to help reduce fluid volume and ease breathing.
6. Administer prescribed medications such as nitroglycerin to improve heart function and decrease cardiac workload.
7. Restrict fluid intake to prevent further fluid accumulation in the lungs.
8. Provide emotional support to the client and family to reduce anxiety and promote a sense of calm.
9. Prepare for possible intubation and mechanical ventilation if respiratory distress persists and the client's breathing continues to decline.

In cases of respiratory distress syndrome (RDS), rapid intervention with mechanical ventilation or continuous positive airway pressure (CPAP) may be required along with the administration of pulmonary surfactant. Excess fluid in the lungs, characteristic of pulmonary edema, often results from heart failure and compromises gas exchange, necessitating aggressive and prompt treatment to prevent further deterioration.