Question

UAP reports urinary output of 50 mL over the past three hours. Repeat focused pulmonary assessment reveals profound bilateral atelectasis in the bases and frothy white sputum. Increased Respiratory rate of 32 and labored, peripheral edema +3 in both ankles and JVD. Based on findings, nursing care actions that are most concerning are:

A)Administering prescribed medications
B)Monitoring urinary output
C)Assessing respiratory status
D)Evaluating peripheral edema and JVD

Answer 1

The patient's symptoms of profound bilateral atelectasis, frothy white sputum, and increased respiratory rate with labored breathing are indicative of pulmonary edema or heart failure. Assessing respiratory status and evaluating peripheral edema and JVD are the nursing care actions most concerning and should be prioritized due to their life-threatening nature.

Step-by-step explanation:

The case presented involves a patient displaying symptoms of profound bilateral atelectasis, frothy white sputum, increased respiratory rate with labored breathing, peripheral edema, and jugular venous distension (JVD). These signs are concerning and may indicate a serious condition such as pulmonary edema or heart failure which can compromise gas exchange and are life-threatening. The nursing care actions that are most concerning are:

• Assessing respiratory status - This is critical as the patient is showing signs of difficulty in breathing and crackling sounds in the lungs, which could denote fluid accumulation and require immediate intervention.
• Evaluating peripheral edema and JVD - These symptoms can indicate heart failure or fluid overload, necessitating prompt assessment and treatment to prevent further complications.

While administering prescribed medications and monitoring urinary output are also important, the urgency of the respiratory and circulatory symptoms requires immediate attention to prevent the development of more severe conditions such as shock or organ failure, as indicated in the clinical focuses provided.