Heart Failure, Pulmonary Edema: Priority Actions Practice Test

A 62-year-old client with known heart failure presents to the emergency department after missing diuretics for 3 days. Assessment: blood pressure 174/100 mm Hg, heart rate 122/min, respiratory rate 30/min, oxygen saturation 86% on room air, crackles to the apices, and bilateral 2+ edema. Which intervention should the nurse implement IMMEDIATELY?

A 68-year-old postoperative day 1 client after hip repair has a history of heart failure with reduced ejection fraction and received 2 L of intravenous fluids overnight for hypotension. Current findings: blood pressure 148/86 mm Hg, heart rate 112/min, respiratory rate 28/min, oxygen saturation 88% on 2 L nasal cannula, new crackles at bases, and jugular venous distention. What is the nurse's PRIORITY action for this client?