A client arrives on the cardiac unit from the emergency room with a diagnosis of heart failure exacerbation. The nurse receives the client who is acutely short of breath with respiratory rate of 40, pulse oximetry 85%, blood pressure 150/90, and lower extremity swelling. What intervention or action should the nurse take first?

Choice A reason: Fluid and nutrition support overall health but aren’t direct outcomes for peripheral perfusion in artery disease. Warm skin and palpable pulses indicate improved circulation, making this incorrect, as it’s not specific to the nursing diagnosis of ineffective tissue perfusion.

Choice B reason: Adequate urinary output reflects renal perfusion, not peripheral artery disease’s limb perfusion. Palpable pulses are more relevant, making this incorrect, as it does not directly address the peripheral tissue perfusion outcome in the client’s nursing care plan.

Choice C reason: Respiratory distress is unrelated to peripheral artery disease, which affects limb circulation. Warm, dry skin is a perfusion outcome, making this incorrect, as it does not pertain to the nursing diagnosis of ineffective tissue perfusion in the client’s extremities.

Choice D reason: Warm and dry skin indicates improved peripheral perfusion in artery disease, reflecting better blood flow. This aligns with nursing outcomes for tissue perfusion, making it a correct outcome the nurse would expect for the client’s peripheral artery disease management.

Choice E reason: Palpable peripheral pulses demonstrate effective blood flow, a key outcome for peripheral artery disease perfusion. This aligns with vascular nursing goals, making it a correct outcome the nurse would include for the client’s ineffective tissue perfusion diagnosis.

Choice A reason: Octreotide reduces portal hypertension and bleeding in esophageal varices by constricting splanchnic blood flow. This aligns with acute variceal bleed management, making it the correct medication the nurse would expect to be administered to the actively bleeding client.

Choice B reason: Propranolol prevents variceal bleeding long-term but is not used for active bleeding. Octreotide is acute treatment, making this incorrect, as it’s inappropriate for the nurse’s expectation in managing the client’s immediate esophageal variceal hemorrhage.

Choice C reason: Lactulose treats hepatic encephalopathy, not active variceal bleeding. Octreotide controls acute hemorrhage, making this incorrect, as it’s unrelated to the nurse’s priority of administering a medication to stop the client’s esophageal variceal bleeding in the emergency.

Choice D reason: Spironolactone manages ascites in liver disease, not acute variceal bleeding. Octreotide is the treatment for active bleeding, making this incorrect, as it’s irrelevant to the nurse’s expectation for a medication to control the client’s esophageal variceal hemorrhage.