A client diagnosed with heart failure presents with a temperature of 99.1° f, pulse 100 beats/minute, respirations 42 breaths/minute, bp 110/50 mm hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. which finding indicates a need for immediate attention?

Since this is a known case of congestive heart failure, the general finding of lung congestion indicates a need for immediate attention. Also, the patient has deranged vital signs and needs attention. The blood pressure of the patient, particularly the diastolic blood pressure, is dropping (since the normal diastolic blood pressure is 60) and the patient may be in the early stages of shock. In the event of heart failure, most commonly in left sided heart failure, there is passive congestion of the lungs caused by pooling of the blood in the pulmonary circulation because of failure of the left ventricle to contract adequately. This will present as an increased respiratory rate and a low oxygen saturation as well as crackles indicating transudation; and this will be addressed as the patient's heart failure is managed.