Question

The patient is diagnosed with heart failure. The nurse finds the patient lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first?

1- Call 911 for the paramedics.
2- Assist the patient to a sitting position.
3- Assess the patient's vital signs.
4- Asuscultate the patient's lung sounds.

Answer 1

The nurse should call 911 for the paramedics first as the patient's symptoms indicate severe respiratory distress. Assisting the patient to a sitting position, assessing vital signs, and auscultating lung sounds are important steps but should be done after calling for emergency medical assistance.

Step-by-step explanation:

The nurse should implement the intervention of calling 911 for the paramedics first. The patient's symptoms indicate a serious condition, and the presence of buccal cyanosis suggests that the patient may be experiencing severe respiratory distress. Calling for emergency medical assistance is crucial to ensure immediate treatment and stabilization of the patient.

While assisting the patient to a sitting position is important for improving breathing and alleviating symptoms in a less severe situation, it is not the priority when the patient is exhibiting signs of respiratory distress and buccal cyanosis.

Assessing the patient's vital signs and auscultating lung sounds are both important steps in the nursing care of a patient with heart failure, but they should be done after initiating emergency medical assistance.