The nurse is assessing a patient in the intensive care unit for congestive heart failure. The patient was fluid resuscitated overnight due to hypotension. She also experienced changes in level of consciousness. The patient has been normotensive and alert for several hours but suddenly complains that she cannot catch her breath. The nurse’s assessment reveals wheezing, tachycardia, and cool, clammy skin. Which of these priority nursing interventions does the nurse anticipate performing?
Select all that apply.
A. Restart the fluid resuscitation protocol.
B. Position the patient in high Fowler’s position.
C. Initiate oxygen therapy via face mask.
D. Perform a 12-lead ECG.
E. Hold the patient’s scheduled hydrochlorothiazide.