# A nurse is caring for a patient in cardiogenic shock following an acute myocardial infarction. The patient's blood pressure is 80/50 mmHg, heart rate is 120 bpm, and urine output has decreased to 15 mL/hr. Which nursing intervention should be the highest priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177132  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a patient in cardiogenic shock following an acute myocardial infarction. The patient's blood pressure is 80/50 mmHg, heart rate is 120 bpm, and urine output has decreased to 15 mL/hr. Which nursing intervention should be the highest priority?

The nurse must prioritize interventions for a patient experiencing cardiogenic shock with hemodynamic instability and decreased organ perfusion.

## 보기

1. Administer prescribed diuretics to reduce fluid overload and improve cardiac output
2. Increase the rate of intravenous fluid administration to raise blood pressure
3. Position the patient in Trendelenburg position to enhance venous return
4. Monitor for signs of pulmonary edema and prepare for possible mechanical ventilation **✔ 정답**

**정답: 4**

## 해설

In cardiogenic shock, the heart's pumping ability is severely compromised, leading to decreased cardiac output and tissue perfusion. The priority is monitoring for life-threatening complications like pulmonary edema while preparing for advanced interventions.

Cardiogenic shock is a life-threatening condition where the heart's pumping function is severely impaired, resulting in inadequate tissue perfusion and organ dysfunction. After an acute myocardial infarction, damaged myocardial tissue reduces the heart's contractility, lowering cardiac output, and the compensatory mechanisms ultimately worsen the condition.

The patient's hypotension (80/50 mmHg), tachycardia (120 bpm), and oliguria (15 mL/hr) indicate severe hemodynamic compromise. These findings suggest that the body's compensatory mechanisms are failing and there is a high risk of blood backing up into the pulmonary circulation, leading to pulmonary edema.

Monitoring for signs of pulmonary edema and preparing for mechanical ventilation is the top priority because respiratory failure is often an immediate cause of death in cardiogenic shock. Early recognition of pulmonary edema symptoms (dyspnea, crackles, pink frothy sputum) allows for rapid intervention. Mechanical ventilation may be necessary to maintain adequate oxygenation and reduce the work of breathing, thereby decreasing myocardial oxygen demand.

The nursing priority focuses on supporting cardiac function while maintaining adequate oxygenation and ventilation. This approach addresses the most immediate life-threatening complication while buying time to implement other interventions such as inotropic support, mechanical circulatory assistance, and emergency cardiac catheterization.

## 심화 해설

Understanding the Priority in Cardiogenic Shock

The patient's presentation—hypotension (80/50 mmHg), compensatory tachycardia (120 bpm), and severe oliguria (15 mL/hr)—paints a clear picture of cardiogenic shock with end-organ hypoperfusion. In this state, the heart's pumping failure leads to a cascade of backward and forward flow issues. The immediate threat to life is not solely the low blood pressure, but the progression to respiratory failure from pulmonary congestion, a direct consequence of the left ventricle's inability to eject blood forward.

Analysis of the Correct Answer

The highest priority is to **monitor for signs of pulmonary edema and prepare for possible mechanical ventilation**. In the setting of an acute myocardial infarction, the damaged myocardium becomes stiff and non-compliant. As blood backs up into the pulmonary vasculature, pulmonary edema develops rapidly, impairing gas exchange. This creates a vicious cycle where hypoxemia further depresses cardiac function. Current management strategies for severe cardiogenic shock, as highlighted in the literature, emphasize stabilization of gas exchange and hemodynamics, often requiring temporary mechanical circulatory support like venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to recovery or definitive therapy [1]. Before such advanced support is initiated, or if it is not immediately available, ensuring adequate oxygenation and ventilation is a fundamental nursing action to prevent imminent respiratory arrest. The consensus on cardiogenic shock underscores that timely delivery of optimal care is critical to improving outcomes, and this begins with addressing the most acute physiological derangements, which often involve the respiratory system [2].

Why the Other Options Are Incorrect

**1. Administer prescribed diuretics to reduce fluid overload and improve cardiac output:** While pulmonary congestion is a concern, administering a diuretic to a patient with a blood pressure of 80/50 mmHg is dangerous. Diuretics reduce intravascular volume, which can cause a further catastrophic drop in preload and cardiac output, worsening hypotension and organ perfusion. The priority is to stabilize oxygenation and perfusion, not to aggressively diurese a hemodynamically unstable patient.

**2. Increase the rate of intravenous fluid administration to raise blood pressure:** This is a common intervention for other types of shock (e.g., hypovolemic or distributive), but it is potentially harmful in cardiogenic shock. The problem is not a lack of volume, but a failure of the pump. Aggressive fluid boluses can over-distend the failing left ventricle, increase myocardial wall stress and oxygen demand, and precipitate acute pulmonary edema, directly hastening respiratory failure.

**3. Position the patient in Trendelenburg position to enhance venous return:** The Trendelenburg position (head down, feet up) is no longer routinely recommended for hypotension. In cardiogenic shock, this position shifts abdominal contents against the diaphragm, making breathing more difficult, and increases venous return to a heart that is already failing, which can worsen pulmonary congestion and increase intracranial pressure. The patient's hemodynamic instability requires advanced support strategies, such as those described in case reports where mechanical support systems are used to stabilize the patient for definitive interventions like heart transplantation .References (research sources)

- [1]A Contemporary Guide of Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock.Research articleChau VQ, Kalapurakal G, Imamura T, Chung BB, Loberg S, Beckett A, Tatooles AJ, Narang N. (2025) · DOI: 10.3390/jcdd12120475

- [2]SCAI/EAPCI/ACVC Expert Consensus Statement on Cardiogenic Shock in Women: This statement was endorsed by the Heart Failure Society of America (HFSA).GuidelineBaron SJ, Chou JC, Shah T, Vest AR, Abbott JD, Alasnag M, Aurigemma C, Barbato E, Bellumkonda L, Bortnick AE, Chieffo A, Geuns RV, Grines CL, Halvorsen S, Hassager C, Kapur NK, Naidu SS, Ng VG, Saw J, Lansky AJ. (2025) · DOI: 10.1016/j.jscai.2024.102150

## 임상 시나리오

Cardiogenic Shock: Nursing PriorityImmediate focus on respiratory status over fluid or positioning
In cardiogenic shock following an acute MI, the failing left ventricle causes blood to back up, rapidly leading to pulmonary edema. The initial priority is to ensure oxygenation and ventilation.

Assess for signs of respiratory distress: tachypnea, crackles, frothy sputum, and declining SpO2. Prepare for mechanical ventilation to break the cycle of hypoxemia worsening cardiac function.

CautionAvoid Trendelenburg positioning and rapid IV fluid boluses; they can worsen pulmonary congestion and do not address the underlying pump failure. Diuretics are used cautiously as they may drop preload and further reduce cardiac output.

## 핵심 개념

- **Cardiogenic Shock** — A state of end-organ hypoperfusion due to the heart's inability to pump effectively, often following an acute myocardial infarction.
- **Pulmonary Edema** — Accumulation of fluid in the lung interstitium and alveoli, a common consequence of left ventricular failure causing backward pressure into the pulmonary circulation.
- **Oliguria** — Urine output less than 400 mL/day or 30 mL/hr, indicating decreased renal perfusion and a sign of shock.
- **Hemodynamic Instability** — Abnormal or unstable blood pressure and heart rate, leading to inadequate blood flow to organs.
- **Mechanical Ventilation** — A life-support intervention that assists or replaces spontaneous breathing to ensure adequate oxygenation and carbon dioxide removal.

## 같은 주제 문제

- [A nurse is caring for a patient in the emergency department who presents with signs of dis…](https://mymerci.kr/pages/nclex_q.php?qn_id=177119)
- [A nurse is caring for a patient in the emergency department who presents with signs of dis…](https://mymerci.kr/pages/nclex_q.php?qn_id=177120)
- [A nurse is caring for a patient in the emergency department who presents with signs of dis…](https://mymerci.kr/pages/nclex_q.php?qn_id=177121)
- [A 45-year-old patient is admitted to the emergency department following a motor vehicle ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=177122)
- [A 45-year-old patient is admitted to the emergency department with signs of distributive s…](https://mymerci.kr/pages/nclex_q.php?qn_id=177123)
- [A 35-year-old patient is brought to the emergency department following a motor vehicle acc…](https://mymerci.kr/pages/nclex_q.php?qn_id=177124)
- [A 68-year-old patient with a history of coronary artery disease presents with cardiogenic …](https://mymerci.kr/pages/nclex_q.php?qn_id=177125)
- [A patient in cardiogenic shock is receiving dopamine at 10 mcg/kg/min and has a central ve…](https://mymerci.kr/pages/nclex_q.php?qn_id=177126)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._