A nurse is caring for a patient with a confirmed pulmonary embolism who is receiving anticoagulant therapy. Which nursing intervention should be the highest priority?

For a patient with a confirmed PE, the highest priority according to the ABCs (Airway, Breathing, Circulation) framework is optimizing respiratory function. Positioning the patient in high Fowler's position and encouraging deep breathing immediately maximizes lung expansion, decreases the work of breathing, and improves oxygenation. While monitoring for bleeding risks associated with anticoagulant therapy is essential, it is secondary to addressing the acute and life-threatening respiratory compromise..

Understanding the Priority: Airway, Breathing, and Circulation (ABCs)

In the NCLEX-RN framework, when a patient presents with an acute condition like a pulmonary embolism (PE), the nursing process must always begin with the ABCs (Airway, Breathing, Circulation). While all the listed interventions are essential components of care for a patient on anticoagulation, the highest priority is the intervention that directly addresses a life-threatening physiological derangement. In PE, the primary pathophysiological problem is a ventilation-perfusion (V/Q) mismatch caused by an obstructed pulmonary artery. This obstruction impedes blood flow to functional alveoli, preventing proper gas exchange and leading to acute hypoxemia. The 2026 AHA/ACC guideline emphasizes a structured approach to immediate management based on clinical severity, which inherently prioritizes stabilization of oxygenation and hemodynamics ^[1]. Therefore, positioning the patient to optimize ventilation and perfusion mechanics is the most immediate, independent nursing action to mitigate this mismatch.

Rationale for the Correct Answer (Option 3)

Positioning the patient in high Fowler's position and encouraging deep breathing exercises directly targets the compromised respiratory function. High Fowler's position facilitates maximal chest expansion and reduces the pressure of the abdominal organs on the diaphragm, thereby decreasing the work of breathing. Encouraging deep breathing and coughing helps to expand atelectatic alveoli and mobilize secretions, which can further improve gas exchange in the unaffected lung segments. This intervention is a non-pharmacological, immediate nursing action that can be implemented without delay to improve the patient's oxygenation status, aligning with the guideline's focus on initial stabilization based on clinical severity assessment ^[1].

Analysis of Incorrect Options

Option 1 (Monitor oxygen saturation and administer supplemental oxygen) is a critical intervention, but it is a collaborative and supportive measure that follows the primary assessment and positioning. While the guideline supports oxygen therapy to maintain normoxia, the nurse can first optimize ventilation mechanics through positioning, which may reduce the oxygen requirement and is a foundational step before or alongside applying oxygen ^[1].

Option 2 (Assess for signs of bleeding and monitor coagulation studies) is a crucial safety intervention for a patient on anticoagulant therapy, as highlighted by the guideline's emphasis on balancing thrombotic and bleeding risks. However, this addresses a potential complication of the treatment, not the immediate, life-threatening hypoxemia caused by the embolism itself. In the acute phase, ensuring adequate oxygenation takes precedence over monitoring for a therapeutic side effect ^[1].

Option 4 (Educate the patient about activity restrictions and fall prevention) is an important long-term safety measure to prevent bleeding from trauma while on anticoagulation. However, patient education is a lower priority in the acute, unstable phase of care when the patient is experiencing a physiological crisis. The immediate need is to stabilize the patient's respiratory status, as reflected in the guideline's structured approach to acute management ^[1].