A nurse is caring for a client with severe asthma exacerbati… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for a client with severe asthma exacerbation who has been receiving continuous nebulized albuterol treatments. The client's peak expiratory flow rate (PEFR) remains at 40% of personal best despite treatment. Which nursing intervention should be the priority?

해설
PEFR remaining at 40% despite continuous albuterol indicates severe airway obstruction and impending respiratory failure, requiring immediate preparation for intubation. Other options are less urgent or inappropriate for this critical situation.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to recognize impending respiratory failure in a patient with a severe asthma exacerbation. The key data point is the Peak Expiratory Flow Rate (PEFR) remaining at 40% of personal best despite aggressive bronchodilator therapy. In asthma management, PEFR is a crucial objective measure of airway obstruction. A PEFR < 40% of personal best or predicted is a red flag indicating a Key Point! life-threatening or near-fatal asthma attack that is not responding to initial treatment.

Answer Rationale: The priority intervention is to Prepare for potential intubation and notify the healthcare provider immediately. This is based on the ABC (Airway, Breathing, Circulation) priority framework. The patient's airway and breathing are critically compromised and deteriorating despite standard therapy. The nurse's role is to anticipate the need for advanced airway management (endotracheal intubation and mechanical ventilation) and to escalate care urgently by notifying the provider. Delaying this action to try less invasive measures first could lead to respiratory arrest.

Distractor Analysis:
Watch out for confusion! Option ①: Increasing albuterol frequency is incorrect because the patient is already on continuous nebulized albuterol, which is the maximum frequency. Further increases are not standard and could lead to dangerous side effects like tachycardia and tremors without additional benefit.
Option ②: Administering oral prednisone is an important intervention for reducing inflammation, but it is not the priority in this imminent crisis. Systemic corticosteroids have a delayed onset of action (several hours) and do not address the immediate life-threatening bronchospasm.
Option ④: Positioning and breathing techniques are supportive measures for respiratory distress but are utterly insufficient as the primary intervention for a patient in impending respiratory failure. They do not address the severe physiological obstruction.

Related Concepts: This scenario illustrates the concept of status asthmaticus—a severe, prolonged asthma attack unresponsive to standard therapy. Nursing management shifts from routine care to emergency preparedness, focusing on early recognition of deterioration and preparation for intensive care. Concept Summary
ConceptDescriptionClinical Significance
Peak Expiratory Flow Rate (PEFR)Measures maximum speed of expiration. Personal best is the patient's known highest value when well.Green Zone (>80%): Good control. Yellow Zone (50-80%): Caution, adjust therapy. Red Zone (

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a medical-surgical unit. Your patient, Mr. Jones, was admitted 6 hours ago for an asthma exacerbation. He is on continuous nebulized albuterol, IV steroids, and oxygen at 4 L/min via nasal cannula. His initial agitation has decreased, and he now appears lethargic. His SpO2 is 89%, respiratory rate is 8 breaths/min (down from 32), and his most recent PEFR measurement is 35% of his personal best.

Nursing Intervention Strategy: 1. Immediate Assessment & Action: This change from agitation to lethargy with a slowing respiratory rate is an ominous sign of respiratory fatigue and impending arrest, not improvement. Do not leave the bedside. 2. Call for Help & Prepare: Use the call bell to summon the rapid response team or charge nurse. Verbally delegate: "Please bring the crash cart and intubation tray to room 402." Simultaneously, notify the provider via phone or in-person STAT. 3. While Awaiting the Team: Ensure the patient's airway is patent. Increase oxygen delivery (e.g., switch to a non-rebreather mask at 15 L/min). Have suction equipment ready. Continue all prescribed medications as you are able.

Patient Safety and Precautions:
  • Do Not Mistake Sedation for Improvement: In respiratory distress, a quiet patient is not always a stable patient. A decreasing respiratory effort can signal muscle fatigue and hypercapnia (elevated CO2).
  • Monitor for Albuterol Toxicity: During continuous nebulization, closely monitor heart rate (for tachycardia/arrhythmias), tremors, and serum potassium levels (albuterol can cause hypokalemia).
Nursing Procedure & Medication Flow Procedure: Assisting with Rapid Sequence Intubation (RSI) Preparation 1. Ensure the code cart and intubation tray are at the bedside and unlocked. 2. Check and connect suction: Yankauer and inline suction for the endotracheal tube (ETT). 3. Prepare medications as per protocol/provider order: Common RSI drugs include a sedative (e.g., etomidate) and a paralytic (e.g., succinylcholine or rocuronium). Have them drawn up and labeled. 4. Prepare for post-intubation: Have the ventilator ready with initial settings (e.g., AC mode, tidal volume 6-8 mL/kg ideal body weight, FiO2 100% initially). Have tape or a securement device ready for the ETT. 5. Assign roles if you are the primary nurse: You may be responsible for administering medications, recording events, or managing the airway bag during the procedure. A Word from Your Senior Nurse "Remember, your assessment is your superpower. In a case like this, the numbers (PEFR 40%) tell one story, but the patient's overall presentation tells the complete story. A patient who is tiring out is at the highest risk. On the NCLEX and in practice, thinking one step ahead is what saves lives. Don't just ask 'What is wrong?' Ask 'What could happen next, and what do I need to have ready to prevent it?' That's the essence of critical thinking in nursing."

핵심 개념

  • Status Asthmaticus — A severe, prolonged asthma attack that does not respond to standard treatments with short-acting bronchodilators. It is a medical emergency.
  • Peak Expiratory Flow Rate — The maximum speed of air during a forced expiration. It is used to monitor asthma severity and control, with values compared to the patient's personal best.
  • Endotracheal Intubation — The placement of a tube into the trachea to establish and maintain a patent airway, facilitate ventilation, and provide a route for medication administration.
  • Short-Acting Beta-Agonist — A class of bronchodilator medication (e.g., albuterol) that provides rapid relief of acute asthma symptoms by relaxing bronchial smooth muscle.
  • Respiratory Fatigue — A state where the respiratory muscles become exhausted from the increased work of breathing, often leading to a decrease in respiratory rate and depth, and impending respiratory arrest.

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기
App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.