A nurse is caring for a client with severe asthma who is experiencing an acute exacerbation. The client's peak expiratory flow rate (PEFR) is 30% of personal best, oxygen saturation is 85% on room air, and the client is using accessory muscles to breathe. Which nursing intervention should the nurse implement first?
1Administer prescribed albuterol via nebulizer
2Position the client in high Fowler's position
3Apply oxygen via nasal cannula at 2-4 L/min
4Assess the client's breath sounds and respiratory pattern✓ 정답
해설
In severe asthma exacerbation, assessment (breath sounds, respiratory pattern) must come first to establish baseline data and guide safe interventions like albuterol, oxygen, or positioning. Other options are appropriate but require prior assessment.
This question tests your ability to prioritize nursing interventions for a client in acute respiratory distress using the nursing process. The scenario presents a client with severe asthma exacerbation exhibiting signs of impending respiratory failure: a PEFR of 30% of personal best, oxygen saturation of 85% on room air, and accessory muscle use.
The correct first action is to assess the client's breath sounds and respiratory pattern. In the nursing process, assessment always precedes implementation unless a life-threatening condition requires an immediate, protocol-driven intervention without a focused assessment. While this client is in severe distress, the nurse must first perform a rapid, focused respiratory assessment to gather essential data that will guide and validate all subsequent interventions. You cannot effectively evaluate the outcomes of positioning, oxygen delivery, or bronchodilator therapy without establishing a clear baseline of lung sounds and breathing effort. Administering a bronchodilator, applying oxygen, or repositioning are all implementation-phase actions that depend on the data obtained from this initial assessment.
The provided evidence explores the comparison of high-flow nasal cannula (HFNC) oxygen therapy with conventional oxygen therapy for asthma exacerbations [1]. While this research focuses on a specific oxygen delivery modality, it underscores a critical clinical principle: the management of acute asthma is centered on correcting hypoxemia and reducing work of breathing. The severely diminished PEFR (30%) indicates profound bronchoconstriction and airflow obstruction, which leads to the critical hypoxemia (85%) and the recruitment of accessory muscles. Before deciding on the specific oxygen delivery system—whether a simple nasal cannula, a non-rebreather mask, or an HFNC system—the nurse must first conduct a thorough assessment. This assessment, including auscultation for wheezing, diminished breath sounds, or a "silent chest," directly informs the urgency and type of intervention. For instance, a finding of a silent chest would indicate a far more critical, pre-arrest situation than diffuse expiratory wheezing, potentially altering the sequence and speed of subsequent actions. The assessment is the foundational step that ensures the chosen intervention, such as applying oxygen as explored in the context of HFNC versus conventional therapy, is appropriately targeted and its effects can be accurately monitored [1].
References (research sources)
[1]
High-flow nasal cannula oxygen therapy for asthma exacerbation.Research articleHonda A, Watanabe Y, Abe Y, Kusumoto S, Hasegawa T, Noma H, Ota E, Imai T, Yamaji N, Barroga E. (2025) · DOI: 10.1002/14651858.cd016205
Clinical Practice Guide: Prioritizing Assessment in Acute Asthma Exacerbation
In a client with a severe asthma exacerbation (PEFR 30% of personal best, SpO2 85%, accessory muscle use), the nurse's immediate priority is a rapid, focused respiratory assessment. This aligns with the nursing process, where assessment data must guide and validate all subsequent interventions. The following steps outline the clinical workflow:
Rapid Focused Assessment: Immediately auscultate breath sounds (noting wheezing, air movement, or a silent chest indicating severe obstruction) and observe the respiratory rate, depth, pattern, and use of accessory muscles. This establishes a baseline to evaluate treatment efficacy.
Positioning: Based on assessment findings, assist the client into a High Fowler's or tripod position to maximize lung expansion and diaphragmatic excursion.
Oxygen Therapy: Administer supplemental oxygen to target SpO2 of 92-95%. The choice of device (nasal cannula, simple mask, or high-flow nasal cannula) is guided by the severity of hypoxemia and the client's work of breathing observed during assessment.
Pharmacological Intervention: Administer prescribed rapid-acting bronchodilators (e.g., albuterol via nebulizer) and systemic corticosteroids. Continuously reassess breath sounds and PEFR to monitor the response to therapy.
Ongoing Monitoring: Closely monitor for signs of deterioration, such as decreasing wheeze with reduced air entry, rising PaCO2, or altered mental status, which may signal impending respiratory failure and the need for escalation of care.
This guide emphasizes the foundational principle that a targeted clinical assessment is the essential first step in managing acute respiratory distress, enabling safe and effective implementation of all other interventions.
Nursing Process — A systematic, dynamic framework guiding nursing practice, consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE), where assessment always occurs first.
Peak Expiratory Flow Rate (PEFR) — A person's maximum speed of expiration, measured in liters per minute; a PEFR of 30% of personal best indicates a severe asthma exacerbation.
Accessory Muscle Use — The use of muscles in the neck, chest, and abdomen during breathing, indicating increased work of breathing and severe respiratory distress.