hard · NCLEX-RN physiological
The nurse is caring for a client with severe COPD with documented chronic hypercapnic respiratory failure and pulmonary hypertension who is admitted with decompensated right-sided heart failure (cor pulmonale). Which interventions should the nurse prioritize to manage this client's physiological adaptation? Select all that apply.
- Maintain the client in a high-Fowler's position and organize nursing care to allow for uninterrupted rest periods.
- Administer a rapid, unmonitored 1-liter normal saline fluid bolus to treat a mild decrease in blood pressure.
- Assess the client's lower extremities and immediately notify the provider of bilateral 2+ pitting ankle edema.
- Administer prescribed scheduled oral diuretics and track exact intake, hourly urine output, and daily weights.
- Titrate supplemental oxygen to maintain the prescribed target oxygen saturation of 88% to 92%.
- Ask the unlicensed assistive personnel to perform a baseline cognitive and cranial nerve assessment to rule out stroke.
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