A nurse in an emergency department is caring for a client. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Nurses Notes 0600: Client presents to the emergency department with reports of increasing shortness of breath, anxiety, inability to breathe when lying down, and Increasing edema in the lower extremities. Client states, "I tried to put my shoes on this morning, but my feet are so swollen, I cannot get them on. My spouse made me come and get checked out." Client has productive cough with pink-tinged secretions. Clear breath sounds auscultated. 1+ edema in lower extremities. Denies chest pain. Height 27.2 cm (69 in), weight 95.5 kg (210.5 lb), BMI 31. Reports smoking 1 pack of cigarettes per day for about 30 years. Client reports history of borderline diabetes and hypertension and states, "I don't take any medicine for diabetes. I was just told to watch what I eat. They gave me medicine for my blood pressure, but I rarely take it because it makes me feel bad." Cardiac monitor shows sinus tachycardia. Vital Signs 0605: Temperature 37.3° C (99.1° F) Heart rate 122/min Respiratory rate 22/min Blood pressure 84/58 mm Hg Oxygen saturation 91% on room air

Rationale for correct choices • Increasing shortness of breath: The client reports progressive dyspnea, which may indicate worsening cardiac or pulmonary compromise. Early recognition and follow-up are critical to prevent hypoxia and respiratory failure. Dyspnea on exertion and at rest can signal fluid overload or heart failure, especially with a history of hypertension and borderline diabetes. • Inability to breathe when lying down (orthopnea): Orthopnea reflects pulmonary congestion due to fluid accumulation when supine, a common sign of heart failure exacerbation. This symptom requires follow-up to assess oxygenation and cardiac function. Immediate monitoring and potential interventions, such as supplemental oxygen or diuretics, may be needed. • Increasing lower extremity edema: Edema indicates fluid retention, suggesting worsening heart failure or compromised venous return. Even 1+ edema is significant in the context of recent symptom progression. Monitoring edema helps track volume status and the effectiveness of interventions. • Productive cough with pink-tinged secretions: Pink-tinged sputum may indicate pulmonary edema or early left-sided heart failure. It is a warning sign that alveolar-capillary fluid is leaking into the lungs. Prompt follow-up is necessary to assess respiratory status and consider interventions like diuretics or oxygen therapy. • Heart rate 122/min: Tachycardia reflects the heart’s compensatory response to hypotension and reduced cardiac output. Persistent tachycardia can compromise myocardial perfusion and indicate hemodynamic instability. Continuous monitoring and timely intervention are needed to prevent deterioration. • Blood pressure 84/58 mm Hg: Hypotension in this client indicates decreased perfusion, possibly from poor cardiac output or medication noncompliance. Low blood pressure increases risk for organ hypoperfusion and shock. Immediate follow-up is necessary to stabilize the client and prevent complications. • Oxygen saturation 91% on room air: Oxygen saturation below 92% signals hypoxemia, indicating insufficient oxygen delivery to tissues. Early follow-up is needed to prevent worsening respiratory compromise and support oxygenation. Supplemental oxygen may be required based on assessment. Rationale for incorrect findings: • Temperature 37.3° C (99.1° F): This mild elevation is within low-grade fever range and does not suggest acute infection requiring immediate intervention. While it should be monitored, it is less critical than the client’s cardiovascular and respiratory findings. • Respiratory rate 22/min: Although slightly elevated, this respiratory rate is only mildly tachypneic. In the absence of severe distress or accessory muscle use, it is less urgent than the low oxygen saturation and orthopnea. It still requires monitoring as part of overall respiratory assessment.