Acute pulmonary edema (severe dyspnea, pink frothy sputum, crackles, dropping oxygen saturation) - this is an emergency; sit the client up, give oxygen, and notify provider/call for help.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client is diagnosed with fluid volume excess. Which assessment finding does the nurse expect?
Answer: B. Fluid volume excess produces distended neck veins (jugular venous distention) from increased intravascular volume, along with crackles, edema, and bounding pulses.
Question 2 of 5
A farm worker presents with excessive salivation, lacrimation, urination, defecation, miosis, and muscle fasciculations after pesticide exposure. Which medication is the primary antidote?
Answer: B. Atropine is the primary antidote for organophosphate (cholinergic) poisoning; it blocks muscarinic effects of the excess acetylcholine. Pralidoxime is given with atropine to reactivate acetylcholinesterase.
Question 3 of 5
A nurse evaluates a client 1 hour after starting an IV insulin infusion for DKA. The blood glucose has dropped from 520 to 250 mg/dL. The nurse recognizes that lowering glucose too rapidly increases the risk of which complication?
Answer: A. Excessively rapid correction of blood glucose and serum osmolality in DKA, especially in younger clients, increases the risk of cerebral edema due to fluid shifts into the brain. Glucose is therefore lowered gradually, generally no faster than about 50 to 75 mg/dL per hour, and dextrose is added once glucose nears 200 to 250 mg/dL.
Question 4 of 5
Which initial intravenous fluid does the nurse anticipate administering for fluid resuscitation in a client with hypovolemic shock?
Answer: A. Isotonic crystalloids such as 0.9 percent sodium chloride (normal saline) or lactated Ringer solution are first-line for volume resuscitation because they expand intravascular volume without causing fluid shifts. Hypotonic and dextrose-in-water solutions move into cells and do not effectively restore intravascular volume.
Question 5 of 5
A client with ESRD is being assessed before hemodialysis. Which finding indicates fluid volume overload that should be reported?
Answer: A. Signs of fluid volume overload in ESRD between dialysis sessions include weight gain, hypertension, jugular venous distention, peripheral edema, and crackles in the lungs from pulmonary congestion. Flat neck veins, a low blood pressure, and weight loss instead suggest hypovolemia, not overload.
Keep the streak going with more questions like these, each with a full rationale.
What is fluid volume excess?
Common causes include heart failure, kidney failure, liver cirrhosis, excessive IV fluids, and high sodium intake. It matters because the overloaded vascular space can back up into the lungs and cause pulmonary edema, a life-threatening emergency. The hallmark signs are edema, weight gain, and bounding pulses.
Key points to remember
- Acute weight gain is the most sensitive sign; 1 kg (2.2 lb) equals about 1 liter of retained fluid.
- Cardiovascular findings include bounding pulse, elevated blood pressure, distended neck veins (JVD), and an S3 heart sound.
- Respiratory signs of pulmonary congestion include dyspnea, crackles, cough, and tachypnea.
- Dependent and peripheral pitting edema, and sometimes ascites, develop from fluid retention.
- Hemodilution lowers hematocrit, BUN, and serum osmolality.
- Hypervolemia worsens with high sodium intake because sodium holds water in the vascular space.
Common causes
- HF, renal failure, cirrhosis
- Excess IV fluids, ↑ Na
Signs & symptoms
- Edema, weight gain, ↑ BP
- Crackles, dyspnea, bounding pulse
- JVD, ↑ CVP, S3 gallop
Nursing priorities
- Assess respiratory status (lung sounds, oxygen saturation, work of breathing) as the priority for detecting pulmonary edema.
- Monitor daily weights, intake and output, vital signs, and edema, and place the client in semi-Fowler's position for breathing.
- Administer diuretics (such as furosemide) as ordered and monitor potassium and urine output.
- Restrict fluids and sodium as ordered.
- Monitor for the effectiveness of treatment: weight loss, decreased edema, clearer lung sounds, and increased urine output.
Labs & values
Patient teaching
- Weigh yourself daily at the same time and report a gain of 2-3 lb in a day or 5 lb in a week.
- Limit sodium and fluids as prescribed and read food labels for hidden salt.
- Report increasing shortness of breath, swelling, or rapid weight gain.
Red flags: report now
- Acute pulmonary edema (severe dyspnea, pink frothy sputum, crackles, dropping oxygen saturation) - this is an emergency; sit the client up, give oxygen, and notify provider/call for help.
- Rapid weight gain or worsening shortness of breath - report promptly.
- New or worsening crackles and falling oxygen saturation - escalate.
References
Clinical references for this topic
