The Nurse Is Caring for a Patient with a History

question 9

Multiple Choice

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?

• A) Administer the ordered intravenous diuretic.
• B) Prepare for insertion of a chest tube.
• C) Suction secretions from the patient's respiratory tract.
• D) Have the patient use the ordered incentive spirometer.

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