A nurse is caring for a client who has been admitted to the medical- surgical unit.

Exhibits

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse understand is indicative of pulmonary edema? Select all that apply.

A. Anuria: Anuria, or complete absence of urine output, occurs in later stages of shock when perfusion to the kidneys is severely compromised. It is a late and serious indicator of organ failure, not an early sign.

B. Hypotension: Hypotension typically occurs after compensatory mechanisms begin to fail. In the early stages of shock, blood pressure may still be normal due to vasoconstriction and increased heart rate.

C. Increased respiratory rate: Tachypnea is one of the earliest signs of shock, reflecting the body’s attempt to compensate for tissue hypoxia and metabolic acidosis. It occurs before hypotension or altered mental status and is a key early warning sign.

D. Decreased level of consciousness: Altered mental status occurs as cerebral perfusion worsens, indicating progression of shock. Although concerning, it develops after early compensatory signs like tachypnea have already appeared.

A. Give naloxone 0.2 mg IV STAT:The client presents with pinpoint pupils, severe sedation, and respiratory depression (RR 4/min), which are hallmark signs of opioid overdose. Naloxone, an opioid antagonist, should be administered immediately to reverse these effects.

B. Bag-valve-mask (BVM) ventilations: With a respiratory rate of 4/min and oxygen saturation of 88%, the client is hypoventilating and hypoxic. BVM ventilation should be initiated to ensure adequate oxygenation and ventilation until naloxone takes effect.

C. Chest compressions: Chest compressions are not indicated because the client has a palpable pulse, normal sinus rhythm, and audible heart sounds (S1 and S2 present), indicating that cardiac output is currently sufficient.

D. Defibrillation: There is no evidence of a shockable rhythm like ventricular fibrillation or pulseless ventricular tachycardia. The client has a sinus rhythm and pulse, so defibrillation is not appropriate.

E. Incentive spirometry: Incentive spirometry is a preventive measure for atelectasis, not an emergency intervention. The client is unresponsive and unable to cooperate with this intervention.

F. Chest physiotherapy (CPT): CPT is used for mobilizing secretions and preventing pneumonia. It is not helpful or appropriate in the setting of opioid-induced respiratory depression.

G. Give 2 units of packed red blood cells (PRBCs): Although the hematocrit is slightly low, there’s no evidence of active bleeding or hemodynamic instability warranting transfusion. The dressing is clean, dry, and intact, and vital signs are stable.

H. Obtain crash cart: Due to the client’s deteriorating respiratory status and potential for full respiratory arrest, having emergency equipment (crash cart) immediately available is necessary.

I. Correct electrolyte imbalance(s): Electrolytes are within normal range, so there are no urgent imbalances that need correction at this moment.

J. Give morphine sulfate 2 mg IV x 1 STAT: Giving more opioids would worsen the respiratory depression. Morphine is contraindicated until the cause of the current symptoms is resolved.