A 6-year-old child is brought to the emergency department by her parents. The child appears pale, dyspneic, edematous, has a pulse of 115 bpm, respirations of 38, and oxygen saturation of 80. Apical heart rate is displaced down and laterally. Lungs have harsh rhonchi and rales on auscultation. A diagnosis of congestive heart failure is made. What is the first priority intervention?
• The child is showing signs of poor oxygenation and perfusion. Administering oxygen will enhance the body's supply without increasing demand. This is the priority nursing action in order to reduce tissue damage due to hypoxia.
• If the child has dyspnea, hypoxemia, or cyanosis, supplemental oxygen via hood, mask, or nasal prongs is usually necessary.
The other options are incorrect only because they are not the highest priority intervention, which is always airway and breathing.
• Administration of drugs to slow the heart rate and increase stroke volume and diuretics to reduce fluid overload will likely be ordered.
• Continuous cardiac monitoring provides objective evidence of cardiac function.
• Arterial blood gases and pulse oximetry will provide information about tissue oxygenation.