# A nurse is caring for a patient with acute exacerbation of heart failure who presents with severe dyspnea, bilateral crackles, and oxygen saturation of 88% on room air. Which nursing intervention should be the highest priority?

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> subject: Adult Health

## 문제

A nurse is caring for a patient with acute exacerbation of heart failure who presents with severe dyspnea, bilateral crackles, and oxygen saturation of 88% on room air. Which nursing intervention should be the highest priority?

## 보기

1. Administer prescribed diuretics as soon as possible
2. Obtain daily weight and monitor intake and output
3. Position the patient in high Fowler's position and administer oxygen **✔ 정답**
4. Restrict fluid intake to 1500 mL per day as ordered

**정답: 3**

## 해설

In acute heart failure with severe respiratory distress (O2 sat 88%), the priority is to improve oxygenation and reduce cardiac workload. Positioning in high Fowler's and administering oxygen address this immediately. Diuretics and fluid restriction are important but not as urgent.

## 심화 해설

Clinical Reasoning and Priority Setting in Acute Heart Failure

When a patient presents with an acute exacerbation of heart failure, the immediate threat to life is hypoxemia resulting from pulmonary congestion. The patient's oxygen saturation of 88% on room air, combined with severe dyspnea and bilateral crackles, indicates that the alveoli are filling with fluid, severely impairing gas exchange. In the hierarchy of physiological needs, airway and breathing take precedence over circulatory volume management. Therefore, the highest priority nursing intervention is to optimize oxygenation and reduce the work of breathing immediately.

Positioning the patient in high Fowler's position uses gravity to pull the diaphragm downward and reduce pressure from abdominal contents on the thoracic cavity, which increases lung expansion and decreases venous return to the overloaded heart. Administering oxygen directly addresses the critical hypoxemia. While the provided evidence base focuses on advanced respiratory support modalities, the underlying physiological principle remains consistent: maintaining adequate oxygenation is the foundation of care. For instance, the narrative review on high-flow nasal cannula (HFNC) therapy emphasizes that indices like the ROX index and P/F ratio are used to predict respiratory support failure by continuously evaluating a patient's ability to maintain oxygenation [1]. This underscores that in any acute respiratory distress scenario, the nurse's first action must be to assess and support the patient's immediate ability to oxygenate, which is precisely what high Fowler's positioning and oxygen administration achieve.

The other options are important components of heart failure management but are secondary to stabilizing the airway and breathing. Administering prescribed diuretics (Option 1) will eventually reduce fluid overload and improve pulmonary congestion, but the pharmacological effect is not instantaneous. Obtaining a daily weight and monitoring intake and output (Option 2) is a crucial evaluation strategy for fluid balance over time, not an immediate rescue intervention for acute respiratory failure. Restricting fluid intake (Option 4) is a preventive and long-term management strategy to avoid fluid volume excess, not an action that will resolve the present crisis of severe hypoxemia. The concept of a nurse-driven, protocolized approach to respiratory care, as explored in the study on pulmonary rehabilitation for ICU-discharged patients, further validates that immediate, non-pharmacological respiratory interventions are a core nursing responsibility to improve patient outcomes . In an emergency, the nurse acts to first correct the physiological derangement that poses the most immediate risk of death, which is the profound oxygen deficit.References (research sources)

- [1]Prediction of high-flow nasal cannula failure in critically ill patients: a narrative review.Research articleMuhetaer Y, Zhang SM, Moming A, Liu K, Zhong M. (2026) · DOI: 10.1186/s40560-026-00871-w

## 임상 시나리오

Acute Heart Failure: Immediate PrioritiesAirway and Breathing Take Precedence Over Circulation
In acute pulmonary edema, the ABC framework guides care. The immediate threat is hypoxemia from fluid-filled alveoli. Position the patient in High Fowler's position to maximize lung expansion and apply oxygen therapy to target an SpO2 above 92%.

Pharmacological interventions like loop diuretics and vasodilators follow once oxygenation is stabilized. Continuous monitoring of respiratory status and work of breathing is essential to detect deterioration early.

CautionDo not delay oxygen administration to obtain an ABG or chest X-ray. Severe hypoxemia can lead to cardiac arrest within minutes.

## 핵심 개념

- **High Fowler's Position** — Upright seated position at 60-90 degrees that promotes lung expansion and reduces venous return.
- **Pulmonary Congestion** — Accumulation of fluid in the lung interstitium and alveoli, impairing gas exchange.
- **Hypoxemia** — Low partial pressure of oxygen in arterial blood (PaO2), often indicated by low SpO2.

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