Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum?
A. Call for help.
B. Call the physician.
C. Start an I.V. line.
D. Suction the client.
Correct Answer: A. Call for help
Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population. The other three interventions would immediately follow.
Option B: Note presence of neck and peripheral vein distention, along with pitting edema, and dyspnea; signs of cardiac decompensation and heart failure. Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gasses (ABGs), as indicated.
Option C: Monitor infusion rate of parenteral fluids closely; May use infusion pump, as necessary. Rapid fluid bolus or prolonged excessive administration potentiates volume overload and risk of cardiac decompensation.
Option D: Encourage deep breathing and coughing exercises. Pulmonary fluid shifts potentiate respiratory complications. Turn or reposition, and provide skin care at regular intervals. Decreases pressure and friction on edematous tissue, which is more prone to breakdown than normal tissue.
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