A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?

A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.

B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.

C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.

D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.

Condition Most Likely Experiencing: Heart failure.

The client presents with signs and symptoms consistent with heart failure, including cardiomegaly, bibasilar pleural congestion on chest x-ray, elevated BNP level, and vital signs indicating hypertension (BP 146/98 mm Hg), tachycardia (pulse rate 106/min), and tachypnea (respirations 24/min). Additionally, the client is prescribed medications commonly used to manage heart failure, such as digoxin and carvedilol, and is receiving a diuretic (furosemide) to address fluid overload associated with heart failure.
Action to Take:

Elevate the head of the bed: Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and potentially alleviating symptoms of heart failure, such as dyspnea and orthopnea. It can also help prevent aspiration in clients with compromised cardiac function. Encourage intake of a low-sodium diet: A low-sodium diet is essential in managing heart failure as it helps reduce fluid retention and edema by decreasing fluid volume overload. Sodium restriction helps minimize fluid accumulation, which is crucial in preventing exacerbations of heart failure.
Parameter to Monitor:

Urinary output: Monitoring urinary output is important in assessing fluid balance and response to diuretic therapy in clients with heart failure. Decreased urinary output may indicate worsening heart failure or inadequate response to diuretic therapy, whereas increased output may suggest over-diuresis or improvement in heart failure symptoms.
Blood pressure: Monitoring blood pressure helps assess the effectiveness of treatment in managing heart failure and controlling hypertension, a common comorbidity. Hypertension can exacerbate heart failure, so monitoring blood pressure trends helps guide adjustments in medication therapy to achieve optimal blood pressure control and improve cardiac function.