Question

The nurse enters the room of the client diagnosed with CHF. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

a. Sponge the client's forehead.
b. Obtain a pulse ox reading.
c. Take the client's vitals.
d. Assist the client to a sitting position.

Answer 1

The nurse should first assist the client to a sitting position to improve breathing in a medical emergency caused by CHF symptoms. Other interventions can be done afterwards.

Step-by-step explanation:

When a client with CHF is exhibiting signs of distress, such as gasping for breath, cool and clammy skin, and buccal cyanosis (bluish discoloration of the lips and mouth), it indicates a medical emergency. The nurse should implement the intervention of assisting the client to a sitting position first, as this will help improve the client's breathing by promoting lung expansion and relieving fluid accumulation in the lungs. Sitting upright allows the diaphragm to move more freely, enabling better air exchange. Other interventions, such as obtaining a pulse ox reading to measure oxygen saturation, taking vitals, and sponging the client's forehead to alleviate discomfort, can be done afterwards.