NCLEX PN Practice Tests Practice Question
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
Correct Answer: A
Rationale: In cases of heart failure, shortness of breath can indicate fluid overload. Slowing the IV and raising the head of the bed immediately alleviates pressure on the diaphragm and promotes easier breathing.
Calling the physician (B) is important, but it should occur after addressing the immediate distress. Taking the blood pressure (C) may provide useful information, but it does not directly address the urgent breathing issue. Notifying the charge nurse (D) may be necessary for further assistance, but it does not prioritize the patient's immediate needs. Addressing the client's breathing takes precedence in this scenario.
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