A 58-year-old patient with cirrhosis and chronic obstructive pulmonary disease is admitted with acute respiratory distress. The patient has ascites, wheezing, and oxygen saturation of 88% on room air. Which nursing intervention should be prioritized first?
1Administer prescribed insulin to control hyperglycemia immediately
2Elevate the head of bed to 45 degrees and apply oxygen therapy✓ 정답
3Restrict fluid intake to 1500 mL per day to prevent fluid overload
4Administer prescribed diuretics to reduce peripheral edema
해설
In acute respiratory distress with COPD exacerbation and hypoxemia (SpO2 88%), the priority is to improve oxygenation by positioning and oxygen therapy to relieve distress and prevent respiratory failure. Other interventions address comorbidities but are not immediate priorities.
Clinical Judgment
This question assesses Prioritization and Clinical Reasoning. The patient is at risk for dyspnea and pulmonary edema due to acute exacerbation of heart failure. Notify HCP! Crackles at the bilateral lung bases are a Critical Cue, indicating fluid accumulation in the alveoli. The most threatening problem in this situation is impairment of the Airway and Breathing. Therefore, according to the ABC principle, interventions to stabilize the respiratory status are the top priority. Raising the head of the bed reduces venous return, decreasing cardiac preload, and aids lung expansion. Oxygen therapy directly corrects hypoxemia. Other interventions are important, but have a lower immediate priority compared to the life-threatening acute respiratory problem.
Memory Tip: Priority is ABC! Always remember the order: Airway, Breathing, Circulation. Apply the principle that "breathing comes first."
KR vs US: The ABC principle is applied identically in both Korea and the US. However, the NGN particularly emphasizes the ability to accurately identify the Threat to Life in patients with multiple comorbidities. Hyperglycemia is important in the long term, but the immediate threat to life is respiratory failure.
Clinical Practice Guide
When caring for patients with acute decompensated heart failure, monitoring respiratory status (respiratory rate, oxygen saturation, lung auscultation) is the most important. The High Fowler's position, raising the head of the bed to 45-90 degrees, is a standard intervention. Administer oxygen as prescribed, but if hypoxemia persists or worsens, report immediately.
Caution: In SATA (Select All That Apply) questions that ask for the "highest priority (first)" intervention, you must select only one. Be careful of the trap where all important interventions are listed, and you must choose one based on the degree of life threat.
Acute Exacerbation of Heart Failure — Acute exacerbation of heart failure. A condition where symptoms (dyspnea, edema, etc.) suddenly worsen, often accompanied by pulmonary edema.
Crackles — Abnormal sounds heard during lung auscultation. Occurs when there is fluid in the alveoli (pulmonary edema, congestion) and is an important sign of worsening heart failure.
High Fowler's Position — Position the head of the bed elevated to 45-90 degrees. For patients with breathing difficulties, this promotes lung expansion and reduces venous return to the heart, easing breathing and cardiac workload.
Preload — Tension (stretch) on the ventricular wall at the end of diastole. It essentially refers to the volume of blood entering the ventricle, and excessive preload in heart failure causes dyspnea.
Comorbidities — Comorbidities. One or more additional disease states that exist alongside the primary diagnosis (in this case, diabetes mellitus, chronic kidney disease). This adds complexity to setting treatment and nursing care priorities.