A 70-year-old patient with chronic heart failure is admitted to the medical unit with acute exacerbation. What is the nurse's priority action for this patient?
The patient appears to be in acute respiratory distress with signs of fluid overload and pulmonary edema secondary to heart failure exacerbation. Vital signs: BP 170/100 mmHg, HR 125 bpm, RR 32/min, O2 sat 84% on room air.
1Administer oxygen therapy and position the patient in high Fowler's position✓ 정답
2Obtain a 12-lead ECG to assess for cardiac arrhythmias
3Insert a urinary catheter to monitor fluid balance
Administering oxygen therapy and positioning in high Fowler's position is the priority to address acute respiratory distress and hypoxemia in heart failure exacerbation. Other interventions like ECG or diuretics are important but secondary to stabilizing breathing.
Clinical Judgment
This question assesses your ability to apply the principles of prioritization and the ABCs (Airway, Breathing, Circulation). The patient is exhibiting pulmonary edema due to an acute exacerbation of heart failure and severe hypoxemia (O2 sat 88%), and is complaining, "I can't breathe," which is a Notify HCP! situation. The most threatening issue in this scenario is respiratory failure and hypoxia. Therefore, the nurse's highest priority action is to immediately improve the patient's breathing and oxygenation. The High Fowler's position helps with lung expansion and reduces venous return, relieving dyspnea. Simultaneously, oxygen therapy must be initiated to correct the hypoxemia. The other options are all important interventions for managing heart failure, but the life-threatening breathing problem must be addressed first.
Memory Tip
The priority is ABC! It goes Airway, Breathing, Circulation. If the patient says, "I can't breathe," that is the biggest signal. Remember: "Dyspnea + Hypoxemia = Breathing is the top priority."
KR vs US
The ABC prioritization principle is applied identically in both Korea and the US. However, the US NGN emphasizes the CJMM model, which systematizes this clinical judgment process, and assesses the ability to clearly explain the rationale for "why this action takes precedence over others."
임상 시나리오
Clinical Practice Guide
Nursing care for patients with acute pulmonary edema: 1) Immediately place the patient in a high Fowler's position. 2) Administer high-concentration oxygen (usually via a non-rebreather mask) as prescribed. 3) Continuously monitor respiratory status, vital signs, and oxygen saturation. 4) Report to the physician immediately and prepare for further orders, such as administering prescribed diuretics (e.g., furosemide).
Caution
A common pitfall in SATA (Select All That Apply) questions is including actions that are important but not an immediate priority when instructed to choose "all correct interventions." Since this question asks for the "priority action," you must select the single action to be done first.
핵심 개념
Pulmonary Edema — Pulmonary edema. It is a condition in which fluid abnormally accumulates in the interstitial tissue and alveoli of the lungs, and is one of the major complications of heart failure. It interferes with gas exchange, causing dyspnea and hypoxemia.
High Fowler's Position — Fowler's position. This is a position where the head of the bed is raised to about 60-90 degrees, placing the patient in a near-sitting posture. For patients with breathing difficulties, it maximizes lung expansion, helps lower the diaphragm, and reduces venous return to ease the work of breathing.
Hypoxemia — Hypoxemia. It refers to a condition where the partial pressure of oxygen (PaO2) in arterial blood is lower than normal. Clinically, it is assessed using pulse oximetry (SpO2) readings, and generally, a value below 90% is considered a danger sign.
Jugular Vein Distention — Jugular vein distension. This is a swelling of the jugular veins in the neck, indicating increased right ventricular pressure or elevated central venous pressure (CVP). It occurs in right heart failure or fluid overload.
Diuretic — Diuretics. These are drugs that promote the excretion of sodium and water from the body through the kidneys, reducing blood volume and preload. They are used as a mainstay in the treatment of heart failure and pulmonary edema (e.g., Furosemide).