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.
Core Nursing ExplanationKey Concept Analysis: This question tests the fundamental nursing principle of Assessment before Intervention in an emergency respiratory situation. The client is in a severe asthma exacerbation, indicated by a PEFR (30% of personal best), hypoxemia with SpO2 (85%), and the use of accessory muscles. While all actions are important, the nurse must first perform a focused assessment to gather critical data that will inform the safety and appropriateness of all subsequent interventions.
Answer Rationale: Key Point! The correct answer is Assess the client's breath sounds and respiratory pattern. This is the first step of the nursing process. In a rapidly changing clinical scenario, a quick but thorough respiratory assessment (e.g., listening for wheezing, stridor, or silent chest; observing for paradoxical breathing) provides essential baseline data. This assessment determines the severity, guides the urgency of other interventions, and is crucial for evaluating the effectiveness of treatments like bronchodilators or oxygen therapy. You cannot safely or effectively implement other orders without knowing the current state.
Distractor Analysis:
Watch out for confusion! While administering albuterol (option 1) is a critical intervention for an asthma attack, it is not the first nursing action. The nurse must first assess to confirm the appropriateness of the medication and to have a baseline against which to measure its effect.
Positioning in high Fowler's (option 2) facilitates lung expansion and is helpful, but it is a comfort and supportive measure, not the priority action when immediate data collection is needed to guide life-saving treatment.
Applying oxygen (option 3) addresses the critical hypoxemia (SpO2 of 85% is a medical emergency). However, even this urgent action follows a rapid assessment. The nurse needs to assess respiratory effort and pattern to ensure the client can protect their airway and effectively use the supplemental oxygen. Furthermore, in some chronic lung disease patients, high-flow oxygen without assessment can be dangerous.
Related Concepts: This scenario highlights the ABC (Airway, Breathing, Circulation) priority framework. The "B" (Breathing) is compromised. The first step in managing any "B" problem is to Assess the breathing—rate, rhythm, depth, effort, and sounds. It also reinforces the difference between a standing order (like giving albuterol for asthma) and the nurse's independent, immediate action, which is always assessment.Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit. Your patient, Mr. Jones, a 25-year-old with a history of asthma, calls you to the room stating he "can't breathe." You find him sitting upright, leaning forward, with audible wheezing, suprasternal retractions, and speaking in short phrases. His SpO2 monitor reads 85%.
Nursing Intervention Strategy:
1. Immediate Assessment (Your First Action): Introduce yourself calmly. While calling for help (activate rapid response if needed), you immediately auscultate lung sounds (listening for wheezing, diminished sounds, or a silent chest—a dire sign), assess respiratory rate and pattern, check pulse, and observe skin color. This takes 30-60 seconds.
2. Simultaneous & Subsequent Actions:
* Oxygen: Based on your assessment of severe distress and hypoxemia, you apply a non-rebreather mask (NRB) at 10-15 L/min to achieve SpO2 >90%, not a low-flow nasal cannula. You continuously monitor SpO2.
* Medication: You promptly administer the prescribed short-acting beta-agonist (SABA) like albuterol via nebulizer, often combined with ipratropium bromide. You assess lung sounds again 5-10 minutes post-treatment.
* Positioning & Monitoring: Maintain high Fowler's position. Establish IV access for possible corticosteroids (e.g., methylprednisolone) and fluids. Continuously monitor vital signs, PEFR, and mental status.
Patient Safety and Precautions:
* Key Point! A "silent chest" in a patient in extreme respiratory distress is a red flag indicating minimal air movement and imminent respiratory failure. This requires immediate preparation for intubation and mechanical ventilation.
* Monitor for tachycardia and tremors as side effects of frequent SABA administration.
* Be aware of oxygen-induced hypercapnia in patients with a history of COPD overlapping with asthma, though pure asthma patients typically do not have this risk.
Nursing Procedure & Medication FlowManaging Severe Asthma Exacerbation: A Step-by-Step Guide
Establishes baseline, identifies life-threats. Key Point! Auscultation is part of this immediate survey.
2. Call for Help
Alert charge nurse, rapid response team, or provider based on severity.
Ensures resources (RT, MD, crash cart) are en route.
3. Administer Oxygen
Apply high-flow oxygen (NRB mask) to achieve SpO2 >90%.
Corrects hypoxemia, a primary driver of distress and organ damage.
4. Administer Bronchodilators
Give SABA (albuterol) + anticholinergic (ipratropium) via nebulizer back-to-back.
First-line medication to relax bronchial smooth muscle. Monitor for side effects.
5. Establish IV Access
Start IV line for systemic corticosteroids (methylprednisolone) and fluids.
Corticosteroids reduce airway inflammation but have a delayed onset (hours).
6. Continuous Monitoring
Re-assess VS, lung sounds, PEFR, mental status every 5-15 mins initially.
Evaluates treatment response. Deterioration may indicate need for intubation.
A Word from Your Senior Nurse
"In the chaos of a 'can't breathe' situation, your training kicks in. Remember: Look, Listen, Feel before you Do. Your hands-on assessment (listening to those lungs) is your most powerful tool. It tells you if the patient is 'wheezing tight' or 'silently crashing.' That one piece of information changes everything. On the NCLEX, they love to test if you know to assess first, even when the intervention seems obvious. In real life, that habit saves lives."
Asthma Exacerbation — An acute or subacute episode of progressive worsening of asthma symptoms, such as shortness of breath, wheezing, cough, and chest tightness, due to bronchoconstriction, inflammation, and mucus production.
Peak Expiratory Flow Rate — The maximum speed of expiration, measured with a peak flow meter. It is a key tool for monitoring asthma control. Personal best is the highest reading achieved when well. <50% of personal best indicates a severe exacerbation.
Accessory Muscles — Muscles of the neck (sternocleidomastoid), shoulders, and abdomen that a person uses to assist breathing when the work of breathing is significantly increased, as seen in severe respiratory distress.
Short-Acting Beta-Agonist — A class of bronchodilator medication (e.g., albuterol) that provides rapid relief of acute asthma symptoms by relaxing the smooth muscle around the airways. It is a rescue medication.
High Fowler's Position — A patient position where the head of the bed is raised to 60-90 degrees. This position maximizes lung expansion by lowering the diaphragm and is used for patients with respiratory difficulties.