The nurse is assigned to four patients in a long-term care facility.
Which patient has the highest risk for pulmonary edema?

Choice A rationale

While IV access is important for fluid resuscitation and medication administration, establishing an airway and ensuring adequate oxygenation are the most immediate priorities. The patient's oxygen saturation is critically low at 90%, indicating severe hypoxemia. Following the ABCs of resuscitation (Airway, Breathing, Circulation), addressing the breathing problem takes precedence over initiating an IV line.

Choice B rationale

A chest X-ray is a diagnostic tool that provides crucial information about the underlying pathology, such as a pneumothorax. However, obtaining a chest X-ray takes time and should not delay immediate, life-saving interventions. The patient's respiratory distress and low oxygen saturation require immediate action to support oxygenation, as delayed intervention can lead to respiratory failure and cardiac arrest.

Choice C rationale

The patient's respiratory rate of 38 breaths/min and oxygen saturation of 90% indicate severe respiratory distress and hypoxemia. Administering high-flow oxygen directly addresses the life-threatening lack of oxygen, improving tissue oxygenation and supporting cellular function. This is the most critical first step in managing a patient with compromised breathing, following the ABCs of resuscitation.

Choice D rationale

Preparing for a chest tube insertion is a vital intervention for a suspected pneumothorax, which is suggested by the absent breath sounds. However, this is a procedural step that follows the initial stabilization of the patient's breathing. The immediate priority is to provide oxygen to prevent further desaturation, while simultaneously preparing for definitive treatment. The preparation should happen concurrently with oxygen administration, not before it.

Choice A rationale

Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.

Choice B rationale

Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.

Choice C rationale

Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.

Choice D rationale

Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.