Fairly easy

A patient with heart failure receiving intravenous fluids develops increasing breathlessness, crackles and a falling oxygen saturation. What should the nurse do first?

Correct answer: A. Place the patient in high Fowler position and assess breathing

  • A. Place the patient in high Fowler position and assess breathing
  • B. Encourage oral fluids to improve renal circulation
  • C. Continue the infusion and reassess after the next vital signs
  • D. Place the patient flat and elevate both legs

Explanation

Breathlessness, crackles and falling oxygen saturation suggest pulmonary fluid accumulation. High Fowler position improves lung expansion, and breathing must be assessed promptly because airway and breathing take priority. Continuing fluids or placing the patient flat may worsen pulmonary congestion.

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About Nutrition, Fluids and Electrolytes

Coverage includes nutrients and balanced diets, therapeutic feeding, enteral and parenteral nutrition, intake and output, dehydration, fluid overload and fluid balance calculations. Questions also examine sodium, potassium, calcium and chloride disturbances, their signs and nursing care, while distinguishing enteral feeding through the gastrointestinal tract from parenteral nutrition.

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