A nurse is caring for multiple patients in the emergency dep… | 마이메르시 MyMerci
마이메르시 — 문제와 상세 해설까지 전부 무료 무료로 시작하기
Leadership Management
문제

A nurse is caring for multiple patients in the emergency department. Which patient should the nurse assess first based on the ABCs priority framework?

해설
The patient with suspected epiglottitis (airway threat) is highest priority per ABCs. Other patients have serious conditions (MI, DKA, fracture) but do not pose immediate airway compromise.
같은 주제 다음 문제A nurse is caring for multiple patients in the emergency department. Which patient should …

심화 해설

Priority Setting Using the ABCs Framework

The nurse must apply the ABCs (Airway, Breathing, Circulation) priority framework to determine which patient requires the most immediate assessment. This framework dictates that a compromised airway takes precedence over breathing or circulatory issues because airway obstruction leads to rapid deterioration and death within minutes.

Analysis of Patient Presentations

Option 1: Suspected Epiglottitis is the highest priority. Epiglottitis involves acute inflammation of the epiglottis and surrounding supraglottic structures, which can rapidly progress to complete airway obstruction [2]. The patient’s presentation—sitting upright in a "tripod" position and drooling—are classic signs of a severely compromised airway. The inability to swallow secretions indicates significant supraglottic swelling. This is a "cannot intubate, cannot oxygenate" (CICO) situation waiting to happen, where an emergency surgical airway like a cricothyrotomy may become the only life-saving intervention if the airway is lost [1]. The airway is the immediate priority.

Option 2: Suspected Myocardial Infarction represents a circulation problem. Although a chest pain rating of 8/10 indicates significant myocardial ischemia and requires prompt intervention, the patient currently has a patent airway and is breathing. Per the ABCs, a circulatory issue is prioritized after airway and breathing problems are stabilized.

Option 3: Diabetic Ketoacidosis (DKA) involves a breathing and circulation issue. The patient is lethargic, indicating altered mental status, and is exhibiting Kussmaul respirations, which are deep, rapid breaths compensating for severe metabolic acidosis. While this is a critical condition, the patient is currently ventilating, and the airway is not mechanically obstructed. The immediate threat to life is less acute than a physical airway blockage.

Option 4: Compound Tibia Fracture is a circulation problem. Active bleeding from a long bone fracture can lead to significant blood loss and hypovolemic shock. However, this is a controllable hemorrhage and a circulatory issue. According to the ABCs, it is a lower priority than a patient whose airway patency is in immediate jeopardy.

The patient with epiglottitis is at the highest risk for a sudden, fatal airway closure, making this the nurse's first priority.
References (research sources)
  • [1]
    Emergency cricothyrotomy in five in-hospital "cannot intubate, cannot oxygenate" cases: a case series.Case reportYoshitomi M, Sagara S, Tokuda Y, Inoue T, Koutaki Y, Tokuyama N, Mabe T, Ichikawa A, Hisaka S, Chuman N, Yamamoto M, Mori R, Murakami H, Koga H. (2026) · DOI: 10.1097/ms9.0000000000004680
  • [2]
    Epiglottitis in Patients Treated for Acute Leukemia: Case Series and Systematic Review of the Literature.Meta-analysis/systematic reviewSherban A, Frisch A, Rozenthal A, Buchrits S, Atamna B, Ben-Ner D, Eden S, Atamna A, Ofran Y, Raanani P, Wolach O. (2026) · DOI: 10.1159/000545927

임상 시나리오

Clinical Priority: Airway Management in Epiglottitis

When applying the ABCs framework in the emergency department, a patient with suspected epiglottitis exhibiting the classic signs of tripod posture and drooling must be assessed first. This presentation indicates critical supraglottic swelling with a high risk of rapid progression to complete airway obstruction. The inability to manage secretions is a dire warning sign that the airway is already significantly compromised.

Immediate Nursing Actions
  • Do Not Disturb the Patient: Keep the patient in their position of comfort (usually sitting upright). Do not attempt to lay them flat, inspect the throat with a tongue depressor, or perform any procedure that could trigger laryngospasm and complete obstruction.
  • Assemble Emergency Equipment: Immediately ensure that emergency airway equipment is at the bedside, including a crash cart with difficult airway supplies, a cricothyrotomy kit, and personnel skilled in performing an emergency surgical airway (ENT, anesthesia, or emergency physician).
  • Provide Humidified Oxygen: Administer high-flow, humidified oxygen via a non-rebreather mask or blow-by method if a mask causes distress. Avoid procedures that agitate the patient.
  • Prepare for Definitive Airway Management: The definitive treatment is often endotracheal intubation in a controlled setting (operating room or ICU) with a double setup, meaning a surgeon is prepped and ready for an immediate cricothyrotomy or tracheostomy if intubation fails.
  • Continuous Monitoring: Continuously monitor oxygen saturation, respiratory rate, and work of breathing. Any sudden change, such as a silent chest or sudden decrease in stridor, may signal complete obstruction.
Rationale for Priority Over Other Emergencies

While acute myocardial infarction, diabetic ketoacidosis, and active hemorrhage are all serious, a compromised airway leads to hypoxic cardiac arrest within minutes. The ABCs framework mandates that airway threats be addressed before breathing (DKA) or circulation (MI, hemorrhage) issues. The patient with epiglottitis is in a peri-arrest state regarding their airway, making them the highest priority for immediate assessment and intervention.

핵심 개념

Merci NCLEX-RN Question Bank 3,445 문제 · 로그인 없이 바로 볼 수 있어요

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.