A 78-year-old client with a history of heart failure is admitted to the emergency department reporting sudden onset of shortness of breath and a productive cough with pink, frothy sputum. Their vital signs are: BP 168/98 mmHg, HR 112 bpm, RR 28 breaths/min, SpO2 88% on room air. The nurse should address which of the following first?

Question: A 78-year-old client with a history of heart failure is admitted to the emergency department reporting sudden onset of shortness of breath and a productive cough with pink, frothy sputum. Their vital signs are: BP 168/98 mmHg, HR 112 bpm, RR 28 breaths/min, SpO2 88% on room air. The nurse should address which of the following first?

Answer options:

• Administer prescribed furosemide 40 mg IV push.
• Initiate continuous pulse oximetry monitoring.
• Elevate the head of the bed to a semi-Fowler's position. ✅ Apply oxygen via non-rebreather mask at 10 L/min.

Correct answer: Apply oxygen via non-rebreather mask at 10 L/min.

Explanation: The client's SpO2 of 88% and respiratory distress indicate impaired gas exchange, which is an immediate life threat. Applying oxygen via non-rebreather mask at a high flow rate directly addresses the hypoxemia, following the ABCs (Airway, Breathing, Circulation) prioritization framework.