A patient receiving intravenous maintenance fluids develops new crackles, orthopnoea, and an oxygen saturation of 90%. What should the nurse do first?
Correct answer: A. Raise the head of the bed and apply prescribed oxygen
- A. Raise the head of the bed and apply prescribed oxygen
- B. Increase the intravenous fluid rate to improve circulation
- C. Ask the patient to walk to assess exercise tolerance
- D. Document the findings and reassess at the next round
Explanation
The findings suggest acute fluid overload with impaired oxygenation. Sitting the patient upright and supporting oxygenation addresses breathing immediately, while the infusion should then be reviewed and the prescriber notified.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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