A nurse is caring for a patient with acute leukemia who suddenly develops severe shortness of breath, chest pain, and anxiety. The patient's vital signs are: temperature 101.2°F (38.4°C), heart rate 128 bpm, respiratory rate 32/min, blood pressure 88/54 mmHg, and oxygen saturation 89% on room air. What is the nurse's priority action?

The patient shows signs of respiratory distress with hypoxia (SpO2 89%), tachypnea (32/min), and cyanosis, indicating a life-threatening oncological emergency. Immediate high-flow oxygen and preparation for intubation address the ABC priorities (airway, breathing, circulation) to manage hypoxia and potential respiratory failure.

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to recognize and prioritize care for a potential oncologic emergency in a patient with acute leukemia. The patient's symptoms (severe dyspnea, chest pain, anxiety) combined with vital signs (tachycardia, tachypnea, hypotension, hypoxia) point to a critical, life-threatening condition. The most likely diagnosis here is Leukostasis or Tumor Lysis Syndrome (TLS) with potential cardiac or pulmonary complications, but the immediate nursing priority is always the Key Point! ABCs (Airway, Breathing, Circulation). The patient is in clear respiratory distress with an oxygen saturation of 89% (Normal is >95%), which requires immediate intervention.

Answer Rationale: Option 1 is correct because it directly addresses the most immediate life threat: Key Point! hypoxia and potential respiratory failure. Administering high-flow oxygen is the first step to correct hypoxia. Preparing for emergency intubation is a critical preparatory action because the patient's condition could rapidly deteriorate to respiratory arrest. This action aligns with the nursing process by implementing an immediate intervention for the primary problem of impaired gas exchange.

Distractor Analysis:
Watch out for confusion! Option 2 (Obtain ECG) addresses the chest pain but is not the priority. While an ECG is important, it does not come before stabilizing the patient's airway and breathing. The patient's hypoxia and respiratory distress are more immediately threatening than a potential MI in this context.
Watch out for confusion! Option 3 (Administer anxiolytic) treats a symptom (anxiety) but ignores its cause. The anxiety is likely secondary to hypoxia (a condition called "air hunger"). Sedating a hypoxic patient without first securing their airway and oxygenation can be dangerous and mask deterioration.
Watch out for confusion! Option 4 (Check labs) is an important diagnostic step but is an assessment action, not an immediate life-saving intervention. You treat the patient, not the lab values. Stabilizing the patient's physiological status takes precedence over gathering more data.

Related Concepts: This scenario highlights the concept of oncologic emergencies. In leukemia, a very high white blood cell (WBC) count (>100,000/mm³) can cause leukostasis, where blasts clog microvasculature in the lungs and brain, leading to respiratory failure and stroke. The fever also suggests neutropenic fever, which is another emergency. The nurse must integrate knowledge of the patient's disease (leukemia) with acute assessment skills (ABCs) to act swiftly. Concept Summary

Concept	Key Takeaway
ABC Priority (Airway, Breathing, Circulation)	Always address life-threatening airway/breathing problems before diagnostics or treating symptoms.
Hypoxia Management	SpO2 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on an oncology unit. Your patient, Mr. Jones, a 55-year-old with newly diagnosed AML, calls you to his room stating he "can't catch his breath." You find him sitting upright, diaphoretic, using accessory muscles to breathe, and visibly frightened. Nursing Intervention Strategy: Immediate Assessment & Action (First 60 seconds): While calling for help via the call bell, you apply a non-rebreather mask (NRB) at 15 L/min to deliver high-flow oxygen. You simultaneously assess lung sounds (crackles? absent sounds?), check capillary refill, and note his mentation. Activation & Preparation: You or your colleague calls a Rapid Response Team (RRT) or Code Blue if needed. You ensure the crash cart and intubation tray are readily available. You connect the patient to continuous cardiac and SpO2 monitoring. Ongoing Management & Collaboration: While the team manages the airway, you provide crucial information: "Patient with AML, day 3 of chemotherapy, febrile, now in acute respiratory distress." You anticipate and prepare for orders: stat CBC, CMP, coagulation panel, blood cultures, chest X-ray, and possibly emergent leukapheresis or chemotherapy for leukostasis. Patient Safety and Precautions: Never Leave Alone: A patient in this condition can deteriorate rapidly. Ensure constant observation. Medication Caution: Hold any non-essential medications. Do not administer sedatives or opioids that could suppress respirations until the airway is secure and hypoxia is corrected. Infection Control: The patient has fever and is likely neutropenic. Maintain strict hand hygiene and aseptic technique during any procedure (like IV access). Nursing Procedure & Medication Flow Procedure: Administering High-Flow Oxygen via Non-Rebreather Mask Explain the action quickly but calmly to the patient: "Mr. Jones, I'm putting this mask on you to help you get more oxygen." Ensure the reservoir bag is inflated by occluding the one-way valve and allowing it to fill with oxygen before placing on the patient. Set the oxygen flowmeter to 15 L/min. (A non-rebreather requires >10 L/min to prevent reservoir bag collapse). Place the mask securely over the nose and mouth, adjust the nose piece and strap for a snug but comfortable fit. Continuously monitor SpO2, respiratory rate and effort, and patient color for response to therapy. Preparation for Intubation: Bring the emergency cart to the bedside. Open the intubation kit, check laryngoscope light, prepare endotracheal tubes of various sizes (e.g., 7.0, 7.5, 8.0). Draw up and label emergency medications as per protocol (e.g., sedatives like etomidate or propofol; paralytics like succinylcholine or rocuronium). Ensure suction is set up and functioning at the bedside. A Word from Your Senior Nurse "Scenarios like this are why we drill the ABCs into your head from day one of nursing school. In the panic of a real emergency, your training takes over. That patient's anxiety is real and terrifying—for them and for you. But you are their anchor. Your calm, decisive action to get them oxygen and call for help is what changes outcomes. When you study for the NCLEX, every prioritization question is practice for this moment. Don't just memorize 'oxygen first'; understand why—because without oxygen, everything else fails within minutes. That critical thinking, rooted in pathophysiology, is what makes you a nurse, not just a test-taker." 핵심 개념 Leukostasis — A life-threatening complication of leukemia where a very high number of blast cells increase blood viscosity and cause sludging/blockage in small blood vessels, particularly in the lungs and brain. Oncologic Emergency — A serious, acute condition arising from cancer or its treatment that requires immediate medical intervention to prevent death or severe disability (e.g., leukostasis, tumor lysis syndrome, spinal cord compression). Non-Rebreather Mask — A high-flow oxygen delivery device with a reservoir bag and one-way valves. It delivers high concentrations of oxygen (up to 90-95%) by preventing the patient from rebreathing exhaled air. ABCs (Airway, Breathing, Circulation) — The fundamental, sequential priority framework for patient assessment and intervention in any emergency situation. Airway patency is assessed first, followed by breathing effectiveness, and then circulation. Hypoxia — A state of insufficient oxygen supply at the tissue level. Clinically significant hypoxia is often defined by a pulse oximetry (SpO2) reading of 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.