A nurse is caring for a client with newly diagnosed sarcoidosis. Which nursing intervention should be the priority?
1Encourage increased fluid intake to 3-4 liters per day
2Administer oxygen therapy at 2 L/min via nasal cannula
3Implement strict bed rest to conserve energy
4Monitor for signs and symptoms of respiratory distress✓ 정답
해설
Monitoring for respiratory distress is the priority for sarcoidosis as it can cause progressive pulmonary involvement. Other options like high fluid intake, oxygen therapy, or strict bed rest are not standard initial interventions.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with newly diagnosed Sarcoidosis. Sarcoidosis is a multisystem, granulomatous inflammatory disease of unknown cause. The lungs and lymph nodes are most commonly affected, leading to the formation of non-caseating granulomas. The priority in nursing care is always patient safety, which begins with vigilant Assessment. For a respiratory-related condition, the initial and continuous priority is to monitor for signs of compromise.
Answer Rationale: Key Point! Option ④, "Monitor for signs and symptoms of respiratory distress," is the correct answer because it embodies the first step of the nursing process: Assessment. In a newly diagnosed patient, the extent and progression of pulmonary involvement are unknown. The nurse must establish a baseline and continuously assess for changes in respiratory status (e.g., dyspnea, tachypnea, use of accessory muscles, hypoxia) to detect early deterioration and initiate timely interventions. This is a fundamental, non-invasive, and universally applicable safety measure.
Distractor Analysis:
Option ① (Encourage increased fluid intake): While hydration is generally important, forcing fluids to 3-4 liters per day is not a specific, evidence-based priority for sarcoidosis. It could be contraindicated if the patient has cardiac or renal involvement. This is a supportive measure, not the initial priority.
Option ② (Administer oxygen therapy): Oxygen is a treatment, not an assessment. The nurse should not administer oxygen without a specific order or documented need (e.g., low SpO2). Administering oxygen without indication is inappropriate and bypasses the critical step of assessment.
Option ③ (Implement strict bed rest): Sarcoidosis does not typically require strict bed rest. In fact, activity as tolerated is encouraged to maintain muscle strength and pulmonary function. Strict bed rest can lead to complications like deconditioning, atelectasis, and deep vein thrombosis (DVT).
Related Concepts: The core principle tested here is Prioritization (ABCs - Airway, Breathing, Circulation) and the foundational role of assessment in the nursing process. For any condition potentially affecting the airway or breathing, monitoring respiratory status is paramount. Sarcoidosis can also affect other organs (eyes, skin, heart, nervous system), but pulmonary manifestations are most common and often the primary concern.
Concept Summary
Concept
Key Points for Sarcoidosis
Pathophysiology
Non-caseating granuloma formation, primarily in lungs (interstitial lung disease) and lymph nodes.
Assessment first: Monitor respiratory status, oxygen saturation, and for signs of extrapulmonary involvement.
Common Treatment
Often observation. Corticosteroids (e.g., prednisone) for symptomatic or progressive disease.
Side-by-Side Comparison!
Priority Intervention (Correct)
Why Other Choices Are Not Priority
Monitor for respiratory distress (Assessment)
Action before assessment is unsafe. You must assess need before implementing interventions like oxygen (②) or restrictive measures like bed rest (③). Fluid encouragement (①) is not disease-specific.
Foundation: ABCs & Nursing Process
Rule: Always assess airway, breathing, circulation first. Implement interventions based on assessment findings and physician orders.
Anatomy, Physiology & Pharmacology Points
Lung Involvement: Granulomas form in the lung interstitium, leading to Restrictive lung disease (reduced lung compliance and vital capacity).
Pharmacology: First-line treatment is corticosteroids (e.g., prednisone) to suppress inflammation. Nursing considerations include monitoring for side effects: hyperglycemia, fluid retention, infection risk, and mood changes.
Memory Tips
Think "Assess First": For any NEW diagnosis, especially involving a vital system (respiratory, cardiac, neuro), your first nursing action is almost always monitoring and assessment.
Sarcoidosis = "Granulomas in Lungs": Remember the primary site. If lungs are involved, priority is breathing.
Rule Out Action Before Order/Assessment: NCLEX loves to test if you will do something (give O2, give a drug, restrict activity) without an order or without assessing the need first. Don't fall for it!
High-Frequency NCLEX Topics
This question integrates two high-yield NCLEX concepts: 1) Prioritization (ABCs) and 2) The Nursing Process (Assessment first). You will frequently see questions where the correct answer is an assessment or monitoring action, while distractors are interventions that require an order or specific assessment finding.
Watch Out for Question Variations!
Symptom Identification: "A client with sarcoidosis reports sharp chest pain and increased dyspnea. The nurse should assess for which complication first?" (Answer: Assess for pneumothorax).
Medication Teaching: "The nurse is teaching a client prescribed prednisone for sarcoidosis. Which statement by the client indicates understanding?" (Answer: "I will take my medication with food and report any signs of infection.").
Priority for a Specific Finding: "A client with sarcoidosis has an SpO2 of 88% on room air. Which action should the nurse take first?" (Answer: Apply supplemental oxygen as ordered/per protocol and raise the head of the bed).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit admitting Mr. Johnson, a 45-year-old man newly diagnosed with pulmonary sarcoidosis after a biopsy. He reports a persistent dry cough and mild fatigue but is currently walking and talking without obvious distress. His vital signs are: BP 128/78, HR 88, RR 18, SpO2 96% on room air, Temp 37.0°C.
Nursing Intervention Strategy:
Initial Assessment (Priority): Conduct a focused respiratory assessment. Auscultate lung sounds (note any crackles or diminished sounds), assess work of breathing, measure oxygen saturation, and ask about dyspnea scale (e.g., 0-10). Document a thorough baseline.
Ongoing Monitoring: Schedule regular vital sign checks per unit protocol, with emphasis on respiratory rate and SpO2. Teach the patient to report any increase in cough, shortness of breath, chest pain, or fever immediately.
Collaborative Care: If assessment reveals respiratory distress (e.g., SpO2 < 92%, increased work of breathing), notify the physician promptly, anticipate orders for arterial blood gas (ABG) analysis, chest X-ray, and possibly supplemental oxygen.
Patient Education & Support: Once stable, educate on the disease process, importance of follow-up pulmonary function tests (PFTs), potential need for corticosteroids, and signs of extrapulmonary involvement (eye redness/pain, skin lesions, palpitations).
Patient Safety and Precautions:
Do Not Routinely Administer Oxygen: Only administer O2 if hypoxemia is documented or if ordered for a specific reason.
Monitor for Steroid Side Effects: If the patient is started on corticosteroids, monitor blood glucose, assess for edema, and reinforce infection prevention (hand hygiene, avoiding sick contacts).
Recognize Emergency Signs: Sudden worsening dyspnea could indicate a complication like pneumothorax or pulmonary hemorrhage—require immediate intervention.
Nursing Procedure & Medication FlowFor a patient on corticosteroids (e.g., Prednisone):
Assessment: Check blood glucose (hyperglycemia is common), weight (fluid retention), and for signs of infection before administration.
Administration: Give with food or milk to minimize gastric irritation. Administer in the morning to mimic the body's natural cortisol rhythm and reduce insomnia.
Monitoring: Monitor for "Cushingoid" signs (moon face, buffalo hump), mood changes, and electrolyte imbalances (hypokalemia).
Patient Teaching: Emphasize never stopping the medication abruptly due to risk of adrenal crisis. Dose must be tapered under medical supervision.
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 respiratory pattern or a slight drop in their SpO2 before they become severely distressed is what saves lives. With sarcoidosis, the course is unpredictable. Your vigilant eyes and skilled assessment are the patient's first line of defense. 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!"
Sarcoidosis — A multisystem inflammatory disease characterized by the formation of non-caseating granulomas, most commonly affecting the lungs and lymph nodes.
Non-caseating Granuloma — A cluster of macrophages and other immune cells without central necrosis (caseation), which is the hallmark histological finding in sarcoidosis (vs. caseating granulomas in tuberculosis).
Restrictive Lung Disease — A category of lung disorders characterized by reduced lung volumes and compliance. Pulmonary sarcoidosis causes this due to interstitial inflammation and fibrosis.
Angiotensin-Converting Enzyme — A serum enzyme often elevated in active sarcoidosis; used as a supportive diagnostic marker and to monitor disease activity.
Corticosteroids (e.g., Prednisone) — First-line anti-inflammatory medication for symptomatic or progressive sarcoidosis. Nursing care involves monitoring for side effects like hyperglycemia, infection, and adrenal suppression.