A nurse is caring for an 80-year-old client with end-stage heart failure who has an advance directive refusing intubation. The client is experiencing severe dyspnea, uses accessory muscles to breathe, and has a SpO2 of 85% on 10 L oxygen. The client's family is requesting that 'everything possible' be done. What is the nurse's priority action?

Question: A nurse is caring for an 80-year-old client with end-stage heart failure who has an advance directive refusing intubation. The client is experiencing severe dyspnea, uses accessory muscles to breathe, and has a SpO2 of 85% on 10 L oxygen. The client's family is requesting that 'everything possible' be done. What is the nurse's priority action?

Answer options:

• Reassure the family that the client is comfortable and provide emotional support.
• Assist the client into a high Fowler's position and administer a prescribed anxiolytic. ✅ Contact the physician to discuss the client's current condition and the family's concerns in light of the advance directive.
• Prepare intubation supplies for immediate use in case the client's condition deteriorates further.

Correct answer: Contact the physician to discuss the client's current condition and the family's concerns in light of the advance directive.

Explanation: The nurse's priority is to address the conflict between the client's advance directive and the family's wishes by involving the healthcare team. The physician needs to be aware of the client's current status and the family's request to guide care decisions ethically and legally. While patient comfort is important, clarifying the plan of care based on the advance directive is paramount.