Management of Care: Prioritization and Delegation

The nurse is assigned to a 68-year-old male client admitted with an exacerbation of heart failure. The client has a history of hypertension and chronic obstructive pulmonary disease (COPD). During the morning assessment, the client reports sudden onset of shortness of breath and chest tightness. Current vitals are BP 162/94 mmHg, HR 108 bpm, RR 28 breaths/min, and SpO2 88% on room air. The nurse notes crackles in the bilateral lung bases and 2+ pitting edema in the lower extremities. The client appears restless and is using accessory muscles to breathe.