A nurse is caring for a 68-year-old patient with chronic heart failure who has been admitted with acute exacerbation. The patient presents with dyspnea, bilateral lower extremity edema, and jugular venous distension. Current vital signs: BP 90/60 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. The patient is receiving furosemide 40 mg IV BID and has a fluid restriction of 1500 mL/day. Which nursing intervention should the nurse prioritize first?
1Administer the next scheduled dose of furosemide immediately
2Increase the patient's fluid restriction to 1000 mL/day
3Encourage the patient to ambulate to improve circulation
4Apply supplemental oxygen and position the patient in high Fowler's position✓ 정답
해설
The priority is to address acute respiratory distress and hypoxemia with oxygen and positioning, as these directly support ABCs (airway, breathing, circulation). Other interventions like diuretics or fluid restriction are important but secondary to immediate oxygenation needs.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize care using the ABC (Airway, Breathing, Circulation) framework and the concept of Maslow's Hierarchy of Needs. The patient is experiencing an acute exacerbation of Chronic Heart Failure (CHF), specifically presenting with signs of Right-sided heart failure (Right HF) (edema, jugular venous distension) and Left-sided heart failure (Left HF) (dyspnea, hypoxemia). The most immediate threat to life is Key Point!hypoxemia (O2 sat 88%) and respiratory distress (RR 28/min), which compromises the fundamental physiological need for oxygenation.
Answer Rationale: Option ④ is correct because it directly addresses the patient's impaired gas exchange and breathing. Key Point! Applying supplemental oxygen is a first-line intervention to correct hypoxemia. Positioning the patient in High Fowler's position (sitting upright at 90 degrees) reduces venous return (preload), decreases the work of breathing by allowing full lung expansion, and helps alleviate pulmonary congestion. This intervention aligns with the primary survey of Airway, Breathing, Circulation.
Distractor Analysis:
Watch out for confusion! Option ① (Administer furosemide): While furosemide is a crucial medication for reducing fluid overload in heart failure, it is not the immediate priority when the patient's oxygenation is critically compromised. The diuretic effect takes time. The nurse should first ensure the patient is stable (oxygenated) before administering medications, even scheduled ones.
Option ② (Increase fluid restriction): This addresses the underlying problem of fluid volume excess but is a planning or prescriptive intervention, not an immediate action. Furthermore, changing a physician's order without assessment and collaboration is not within the nurse's independent scope. The current restriction is already in place.
Option ③ (Encourage ambulation): This is contraindicated for a patient in acute respiratory distress with hypotension (BP 90/60 mmHg) and hypoxemia. Ambulation would increase myocardial oxygen demand and worsen the patient's condition. Activity should be restricted to bedrest with bedside commode use during an acute exacerbation.
Related Concepts: This scenario integrates Heart Failure management, oxygen therapy, and nursing prioritization. Remember: Life-threatening issues related to Airway, Breathing, and Circulation (ABCs) always take precedence over other important but less urgent needs like medication administration or long-term management strategies.
Concept Summary
Concept
Key Takeaway
ABC Priority
Airway, Breathing, Circulation. Hypoxemia (Breathing) is the top priority.
Heart Failure Exacerbation
Manifests with fluid overload (edema, JVD) and pulmonary congestion (dyspnea, hypoxemia).
High Fowler's Position
Reduces preload, eases breathing, and is a key non-pharmacologic intervention for pulmonary edema.
Nursing Scope
Independent actions (O2, positioning) vs. dependent actions (meds, changing orders). Prioritize independent actions for immediate threats.
Treats cause of overload but takes 20-60 min for IV effect. Requires stable patient first.
Activity (Option ③)
CONTRAINDICATED
Increases cardiac workload. Bedrest is indicated during acute exacerbation.
Fluid Restriction Change (Option ②)
LOW / Planning
Long-term management strategy, not an immediate action. Requires provider order.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: In heart failure, the weakened heart cannot pump effectively, leading to increased preload (fluid volume returning to heart) and pulmonary congestion. This impairs gas exchange in the alveoli, causing hypoxemia.
Positioning Physiology: High Fowler's position uses gravity to pool blood in the lower extremities, decreasing venous return (preload) to the right heart, which in turn reduces pulmonary capillary pressure and fluid leakage into the lungs.
Pharmacology:Furosemide (Lasix) is a loop diuretic that inhibits sodium reabsorption in the Loop of Henle, promoting diuresis. Monitor for Key Point!hypokalemia, ototoxicity (with rapid IV push), and hypotension.
Memory Tips
ABCs First, Always! When in doubt on priority questions, ask: "Is the Airway open? Is the patient Breathing adequately? Is Circulation intact?" The answer addressing the most compromised "letter" is usually correct.
CHF Exacerbation = "SOB & SWELL": Think Shortness Of Breath (Left HF) and SWELLing/Edema (Right HF). Your first job is to fix the "SOB" with O2 and positioning.
High-Frequency NCLEX Topics
Prioritization using ABCs is arguably the most frequently tested concept on the NCLEX-RN. It is woven into questions on nearly every topic: medical-surgical, maternal, pediatric, and psychiatric nursing. The exam consistently tests your ability to distinguish between an important task and the most urgent, life-preserving task.
Watch Out for Question Variations!
Symptom Focus: "Which finding requires immediate intervention?" → Answer: Hypoxemia (O2 sat < 92%) or severe respiratory distress.
Medication Focus: "The nurse is about to administer furosemide IV. Which patient assessment would cause the nurse to hold the dose and notify the provider?" → Answer: Severe hypotension (e.g., BP 80/50) or anuria.
Discharge Planning Focus: "Which instruction is priority for a patient with HF being discharged?" → Answer: Daily weight monitoring and when to call the doctor (e.g., gain of 2-3 lbs in a day).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit. Mr. Johnson, 68, with a history of CHF, was admitted 4 hours ago. He is anxious, struggling to speak in full sentences, and using accessory muscles to breathe. His SpO2 remains at 88-89% on 2L nasal cannula.
Nursing Intervention Strategy:
Immediate Assessment & Action (ABCs):
Assess airway patency, breath sounds (expect crackles/rales), and work of breathing.
Action: Increase supplemental oxygen per protocol (e.g., apply a non-rebreather mask at 10-15 L/min to achieve SpO2 > 92%).
Assist patient to High Fowler's position, supporting arms on overbed table to facilitate use of accessory muscles.
Reassess vital signs and SpO2 after 5 minutes.
Secondary Assessment & Care:
Ausculate heart sounds (S3 gallop may be present).
Assess edema (pitting scale), JVD level (measure in cm above sternal angle).
Obtain order for STAT chest X-ray and basic metabolic panel (BMP) to check electrolytes, especially potassium after diuretics.
Administer the scheduled IV furosemide after the patient is more stable and oxygenated. Administer slowly IV push (over 1-2 minutes) to avoid ototoxicity.
Monitoring & Evaluation:
Strict I&O (Intake and Output) monitoring. Expect significant diuresis (e.g., >200 mL/hr) after furosemide.
Evaluate effectiveness: Reduced dyspnea, decreased crackles on lung auscultation, improved SpO2, increased urine output, and reduced edema.
Patient Safety and Precautions:
Oxygen Safety: Use caution with oxygen in patients with COPD and a history of hypercapnia (CO2 retention), though in acute CHF, correcting hypoxemia is the priority.
Fall Risk: The patient is weak, hypotensive, and on diuretics. Implement fall precautions: bed in lowest position, call bell within reach, assist to bathroom/commode.
Skin Integrity: Severe edema increases risk for skin breakdown. Perform frequent skin assessments, especially on sacrum and lower extremities. Use pressure-relieving devices.
Nursing Procedure & Medication FlowAdministering IV Furosemide (Lasix) to a CHF Patient:
Pre-Administration Check: Verify order, patient identity (two identifiers). Check baseline blood pressure and potassium level. Hold and notify provider if BP is severely low (e.g., systolic < 90) or if patient is anuric.
Preparation: Draw up correct dose. For IV push, administer undiluted or diluted per facility policy, typically over 1-2 minutes (never rapid bolus).
Administration & Monitoring:
Administer via a patent IV line.
Monitor for tinnitus or hearing changes (signs of ototoxicity).
Place a urinal or bedpan within easy reach. Onset of action is 5 minutes (IV), peak diuresis in 30 minutes.
Monitor BP closely during and after administration.
Post-Administration: Document dose, time, site, and patient response (urine output, change in breath sounds, weight).
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's vital signs early can prevent deterioration. When studying for your boards, don't just memorize — connect everything to a real patient situation and always ask 'why?' That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse! In this case, you didn't just 'give oxygen,' you recognized a failure in gas exchange and intervened to support the most basic human need. That's the heart of nursing judgment."
ABC (Airway, Breathing, Circulation) — The foundational framework for prioritizing patient care. Life-threatening issues with airway, breathing, and circulation are addressed first.
High Fowler's Position — A sitting position at 90 degrees. Used to decrease preload, ease work of breathing, and improve oxygenation in patients with respiratory distress or heart failure.
Hypoxemia — Low level of oxygen in the blood (SpO2 typically < 90%). A medical emergency requiring immediate intervention with supplemental oxygen.
Furosemide — A loop diuretic used to treat fluid overload in conditions like heart failure. Promotes excretion of sodium and water. Monitor for electrolyte loss (especially potassium) and hypotension.
Jugular Venous Distension — Visible bulging of the external jugular veins when the patient is positioned at 45 degrees. A key sign of increased central venous pressure, often seen in right-sided heart failure.