What are the appropriate nursing actions to promote adequate gas exchange for a client with acute decompensated heart failure (ADHF) and unknown cardiac status?

Administer loop diuretics as prescribed.
Administer oxygen as ordered.
Encourage the client to maintain an upright position.
Monitor oxygen saturation, vital signs, and cardiac rhythm.


• Acute decompensated heart failure (ADHF) is a potentially fatal cause of acute respiratory distress

• Auscultation of crackles may indicate pulmonary congestion

• Patients should sit in an upright position to help facilitate oxygen delivery and clear the airways, thereby improving gas exchange

• Oxygen therapy will improve gas exchange by increasing the amount of oxygen available for delivery

• Patients with ADHF usually have fluid-overload, and intravenous diuretics can relieve symptoms and improve gas exchange

• Excess fluid is assessed as hepatomegaly and jugular veinous distention, but this action does not improve adequate gas exchange

• Dysrhythmias can decrease cardiac output. Cardiac monitoring is important, and reporting any dysrhythmias can aid in early intervention to increase cardiac output, but this action does not promote adequate gas exchange

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