A client with heart failure reports dyspnea and anxiety. Upon examination the client is tachycardic and has crackles throughout bilateral lung fields. Which actions will the nurse take now? Select all that apply.

a. Monitor urine output: Monitoring urine output is important in clients with heart failure to assess renal perfusion and renal function. Decreased urine output may indicate worsening heart failure or inadequate response to treatment. Therefore, monitoring urine output is appropriate in this situation to assess the client's fluid status and response to therapy.

b. Assess pulse oximetry: Assessing pulse oximetry is essential to evaluate the client's oxygen saturation levels, especially in a client presenting with dyspnea and crackles throughout bilateral lung fields. Decreased oxygen saturation may indicate respiratory compromise or worsening heart failure. Therefore, assessing pulse oximetry is necessary to monitor the client's respiratory status and guide interventions.

c. Check PT/INR: Checking PT/INR (Prothrombin Time/International Normalized Ratio) is not indicated in this situation. PT/INR monitoring is typically performed in clients on anticoagulant therapy such as warfarin to assess coagulation status and therapeutic levels. It is not directly relevant to the client's current presentation of dyspnea, tachycardia, and crackles.

d. Infuse 0.9% NS with 20 mEq KCl at 50 ml/hr: Infusing normal saline (0.9% NS) with potassium chloride (KCl) is not appropriate based solely on the client's presentation of dyspnea, anxiety, tachycardia, and crackles. While fluid and electrolyte balance are important considerations in heart failure management, administering IV fluids and electrolytes should be guided by the client's fluid status, electrolyte levels, and response to treatment.

e. Administer 40 mg furosemide IV now: Administering furosemide IV (intravenous loop diuretic) is appropriate in this situation to manage the client's symptoms of dyspnea and crackles indicative of fluid overload in heart failure. Furosemide helps promote diuresis and reduce fluid volume, thereby alleviating symptoms of congestion and improving respiratory distress.

a. Check groin dressing: While monitoring the dressing is important, it is not the top priority immediately after the procedure. The nurse should assess other critical aspects first.
b. Review current H&H (hemoglobin and hematocrit): Although monitoring hemoglobin and hematocrit levels is essential, it is not the highest priority at this moment. Immediate post-procedure concerns take precedence.
c. Check blood glucose: Blood glucose monitoring is important, especially if the client has diabetes or other risk factors. However, it is not the priority right after the procedure.
d. Assess pain level: This is the priority intervention. The nurse should assess the client’s pain level, especially at the insertion site. Pain could indicate complications such as bleeding, hematoma, or vascular injury.