NCLEX-RN Quiz
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PHYSIOLOGICAL INTEGRITY
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A 69-year-old post-operative client (abdominal surgery 2 days ago) with a history of heart failure is receiving intravenous maintenance fluids at 125 mL/hr. The client now reports shortness of breath and has frothy sputum. Assessment: respiratory rate 32/min, oxygen saturation 86% on 4 L/min nasal cannula, heart rate 116/min, blood pressure 162/94 mm Hg, crackles throughout, and jugular venous distention. Which intervention should the nurse implement IMMEDIATELY?
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