The nurse’s physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention?1Obtain chest x-ray film immediately.2Notify the primary health care provider.3Place client in a high-Fowler position.4Assess the client’s oxygen saturation level.
The priority nursing intervention in this scenario would be option 4: Assess the client’s oxygen saturation level
The priority nursing intervention in this scenario would be option 4: Assess the client’s oxygen saturation level.
Tachypnea (rapid breathing) and bilateral crackles can be indicative of pulmonary congestion and impaired gas exchange, which are common manifestations of heart failure. Assessing the client’s oxygen saturation level will provide crucial information about the adequacy of oxygenation and tissue perfusion.
To assess the client’s oxygen saturation level, a nurse can use a pulse oximeter, a non-invasive device that measures the oxygen saturation in arterial blood. This measurement is expressed as a percentage and indicates how much oxygen is bound to hemoglobin in the blood. Normal oxygen saturation levels generally range from 95% to 100%.
By assessing the client’s oxygen saturation level, the nurse can determine whether immediate interventions are necessary to improve oxygenation. If the oxygen saturation level is below the normal range, the nurse can take appropriate actions, such as administering supplemental oxygen and notifying the healthcare provider. Prompt intervention can help prevent further deterioration of the client’s condition and mitigate potential complications.
Obtaining a chest x-ray film (option 1) may be necessary to assess the extent of fluid accumulation in the lungs, but it is not the priority intervention in this situation. It can be done after the client’s oxygen saturation level has been assessed.
Notifying the primary healthcare provider (option 2) is important, but it is not the priority intervention at this moment. Assessing the client’s oxygen saturation level should be the first step in addressing the client’s immediate needs.
Placing the client in a high-Fowler position (option 3) may help improve oxygenation by allowing the lungs to expand fully, but it is not the priority intervention. Assessing the oxygen saturation level should be done first to guide further interventions, including positioning the client appropriately.
In summary, the priority nursing intervention for a client with heart failure presenting with tachypnea and bilateral crackles is to assess the client’s oxygen saturation level. This will provide essential information to guide immediate interventions and ensure adequate oxygenation to the tissues.
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