A patient has returned to the cardiac step-down unit following a percutaneous intervention (PCI). The nurse observes that the patient has bleeding at the right-sided femoral sheath site. What is the nurses' first action?

A. Check the patient's temperature: Although assessing temperature is part of a full evaluation, fever is not the priority concern in this scenario. The patient’s moist cough, jugular venous distention, and dyspnea suggest acute fluid overload and worsening heart failure rather than infection. Immediate cardiopulmonary assessment takes precedence.

B. Assess the pulse oximetry reading: Dyspnea and signs of volume overload raise concern for pulmonary edema and impaired oxygenation. Measuring oxygen saturation provides rapid, objective data about respiratory compromise and guides urgent interventions such as oxygen therapy. Hypoxemia must be identified promptly to prevent respiratory failure.

C. Auscultate the lungs: Lung auscultation is essential to assess for crackles, which indicate fluid accumulation in the alveoli due to left-sided heart failure. Detecting pulmonary congestion supports clinical suspicion of fluid overload and helps determine severity, guiding immediate treatment decisions.

D. Contact the provider: The patient is exhibiting signs of acute decompensated heart failure while receiving IV fluids. Prompt provider notification is necessary to obtain orders to adjust or discontinue fluids and initiate diuretic therapy or other interventions to prevent worsening pulmonary edema.

E. Change the fluids to 0.45% sodium chloride: The nurse should not independently change the IV solution without a provider order. Additionally, switching to hypotonic fluids does not address the underlying issue of volume overload and could further complicate the patient’s condition.

F. Administer furosemide as ordered: Although loop diuretics are commonly used in fluid overload, administration depends on an existing order. Since the question prioritizes immediate assessment and escalation, verifying oxygenation and lung status and notifying the provider are the top initial actions unless a standing order is already in place.

A. Place restraints on the patient: While physical restraints may be used for safety if the patient is at risk of removing the endotracheal tube or lines, this does not address the underlying issue of agitation. Restraints are adjunctive, not a primary intervention for managing sedation levels.

B. Instruct the patient to be calm: Verbal reassurance alone is often insufficient for mechanically ventilated patients who are experiencing agitation or anxiety, especially when sedation is inadequate. The patient may be unable to respond effectively due to intubation.

C. Call the provider: Consulting the provider may be necessary if sedation adjustments are outside protocol limits or if complications arise, but bedside nurses can typically titrate sedatives per established protocols based on RASS assessment. Immediate action at the bedside is appropriate first.

D. Increase the rate of the patient's sedative drip: A RASS of +2 indicates the patient is restless and agitated, which may compromise safety, comfort, and ventilator synchrony. Per sedation protocols, the nurse’s best action is to increase the sedative infusion rate to achieve the target sedation level, improving patient comfort and preventing accidental extubation.