A nurse is caring for a 68-year-old patient with multiple comorbidities including diabetes mellitus type 2, chronic kidney disease stage 3, and heart failure with reduced ejection fraction. The patient presents with shortness of breath, bilateral lower extremity edema, and blood glucose of 280 mg/dL. Which nursing action should be the highest priority?
1Administer prescribed insulin to address hyperglycemia
2Assess respiratory status and oxygen saturation levels✓ 정답
3Measure intake and output to monitor fluid balance
4Elevate lower extremities to reduce peripheral edema
해설
Respiratory assessment is the priority using the ABC framework, as shortness of breath in heart failure indicates potential pulmonary edema requiring immediate evaluation. Hyperglycemia and fluid monitoring are important but not immediately life-threatening compared to respiratory compromise.
Clinical Judgment
This question assesses the ability to determine prioritization (Clinical Prioritization) among multiple symptoms in a patient with complex chronic conditions. The key is applying the ABC (Airway, Breathing, Circulation) framework. The patient complains of shortness of breath, which in a heart failure patient could be a sign of pulmonary edema or acute respiratory failure. While a blood glucose of 280 mg/dL and lower extremity edema are also important, the immediate life threat involves the respiratory system. Therefore, the highest priority nursing action is to rapidly assess respiratory status and check oxygen saturation to rule out or confirm hypoxia.
Memory Tip: Priority is always ABC! Remember the order: Airway, Breathing, Circulation. Think "breathing comes first" to make it easy.
KR vs US: The ABC priority principle is the same in both Korea and the US. However, in the NGN exam, questions asking for the "first/initial/priority action" are very common, and applying the ABC framework is key. In clinical practice, when encountering a patient with shortness of breath, auscultating breath sounds and measuring oxygen saturation before checking blood glucose or repositioning is a universal standard.
임상 시나리오
Clinical Practice Guide
When assessing dyspnea in heart failure patients, you must comprehensively evaluate breath sounds (especially for crackles), respiratory rate, oxygen saturation, use of accessory muscles, and anxiety. A blood glucose of 280 mg/dL may require insulin administration, but Notify HCP! if the respiratory status is unstable, you must report to the physician before administering insulin. Patients with both heart failure and chronic kidney disease (CKD) require fluid restriction, and special attention must be paid to electrolyte imbalances when using diuretics.
Caution: In SATA (Select All That Apply) questions, when asked to choose the "single highest priority action," you must select only one action that aligns with the ABC principle. Don't fall into the trap of selecting multiple options thinking "all are important actions."
핵심 개념
Heart Failure with Reduced Ejection Fraction — Heart failure with reduced ejection fraction. A condition where the left ventricle cannot effectively pump blood, resulting in an ejection fraction (EF) reduced to less than 40%. Congestive symptoms occur as fluid accumulates in the lungs and periphery.
Pulmonary Edema — Pulmonary edema. A condition in which fluid abnormally accumulates in the interstitial tissue of the lungs or within the alveoli. A major complication of heart failure, causing acute respiratory distress, crackles, and hypoxia.
Chronic Kidney Disease (CKD) Stage 3 — Chronic kidney disease stage 3. Glomerular filtration rate (GFR) is moderately reduced to 30-59 mL/min/1.73m². The ability to regulate fluids and electrolytes is decreased, making fluid management more complicated in patients with heart failure.
Hyperglycemia — Hyperglycemia. A state where blood glucose concentration is higher than the normal range. It commonly occurs in diabetic patients and, while it can lead to complications in the long term, in the short term it poses a lower acute threat to life than respiratory distress.
Clinical Prioritization — Clinical priority setting. A nursing judgment process that first addresses the most immediate and serious threats to life or function among the patient's multiple problems and needs. The ABC framework is its basic structure.