The nurse is assessing a client with acute heart failure. Which finding would the nurse anticipate?

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.

In this scenario, the client is exhibiting signs of severe respiratory distress, which could indicate worsening acute heart failure and potential respiratory failure.

a. Check MAR for antianxiety medication: While anxiety may exacerbate the client's symptoms, the priority at this moment is to address the acute respiratory distress and ensure adequate oxygenation. Checking the medication administration record (MAR) for antianxiety medication can be done later but is not the immediate priority.

b. Ask when the dyspnea started: While obtaining a thorough history is important for understanding the onset and progression of the client's symptoms, it is not the first action to take in this critical situation. The client's current condition requires immediate intervention to ensure adequate oxygenation and stabilization.

c. Notify the provider: Notifying the provider is important, especially in a situation where the client's condition is deteriorating rapidly. However, this action may take some time, and the priority is to address the client's immediate needs first.

d. Increase oxygen from 3L/minute to 5L/minute: This is the most appropriate action to take first. The client is showing signs of severe respiratory distress with cyanosis and increased work of breathing. Increasing the oxygen flow rate from 3L/minute to 5L/minute can help improve oxygenation and alleviate hypoxemia, which is crucial in the management of acute heart failure exacerbation.