A 74-year-old client with a history of heart failure with re…
Questions
A 74-yeаr-оld client with а histоry оf heаrt failure with reduced ejection fraction (HFrEF, EF 28%) is admitted with acute decompensated heart failure. The client presents with worsening dyspnea at rest, orthopnea, and a 3 kg weight gain over the past 5 days. Current assessment: BP: 100/66 mm Hg HR: 108 bpm RR: 26 breaths/min, labored with accessory muscle use SpO₂: 89% on 2 L/min nasal cannula Lungs: coarse crackles throughout bilateral lung fields Cardiac: S3 gallop, JVD to mid-neck Extremities: 3+ pitting edema to mid-calf bilaterally Urine output: 60 mL over the past 4 hours Mental status: alert but anxious IV access is in place, and the provider has written orders for supplemental oxygen, furosemide IV, labs, and imaging. Which intervention should the nurse implement first?