# A nurse is caring for a patient with acute leukemia who suddenly develops severe shortness of breath, chest pain, and anxiety. The patient's vital signs are: temperature 101.2°F (38.4°C), heart rate 128 bpm, respiratory rate 32/min, blood pressure 88/54 mmHg, and oxygen saturation 89% on room air. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540762 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with acute leukemia who suddenly develops severe shortness of breath, chest pain, and anxiety. The patient's vital signs are: temperature 101.2°F (38.4°C), heart rate 128 bpm, respiratory rate 32/min, blood pressure 88/54 mmHg, and oxygen saturation 89% on room air. What is the nurse's priority action? ## 보기 1. Immediately administer high-flow oxygen and prepare for emergency intubation **✔ 정답** 2. Obtain a 12-lead ECG to rule out myocardial infarction 3. Administer prescribed anxiolytic medication for anxiety 4. Check the patient's complete blood count and coagulation studies **정답: 1** ## 해설 The patient shows signs of respiratory distress with hypoxia (SpO2 89%), tachypnea (32/min), and cyanosis, indicating a life-threatening oncological emergency. Immediate high-flow oxygen and preparation for intubation address the ABC priorities (airway, breathing, circulation) to manage hypoxia and potential respiratory failure. ## 심화 해설 Clinical Presentation and Early Recognition The patient’s sudden onset of severe dyspnea, chest pain, anxiety, fever, tachycardia, tachypnea, hypotension, and hypoxemia in the context of acute leukemia is a classic presentation of differentiation syndrome (DS). DS is a life-threatening complication of differentiation therapy for hematologic malignancies, most notably acute myeloid leukemia (AML), but the clinical picture can manifest in any patient with acute leukemia undergoing such treatment [1]. The syndrome is driven by a systemic inflammatory response as leukemic cells rapidly differentiate, releasing cytokines that increase capillary permeability. This leads to the hallmark features: fever, pulmonary infiltrates causing respiratory distress, pleural or pericardial effusions, and hypotension that can progress to organ dysfunction [1]. The vital signs are critically deranged, with a heart rate of 128 bpm, respiratory rate of 32/min, blood pressure of 88/54 mmHg, and oxygen saturation of 89%, all indicating impending respiratory and hemodynamic collapse. Priority Action and Rationale The nurse’s priority is to immediately administer high-flow oxygen and prepare for emergency intubation. This action directly addresses the two most immediate life threats: severe hypoxemia and respiratory failure. The patient’s oxygen saturation of 89% on room air demonstrates a critical failure of gas exchange, likely due to non-cardiogenic pulmonary edema from capillary leak, a central feature of DS [1]. High-flow oxygen is a temporizing measure to support oxygenation while preparing for definitive airway management. Intubation and mechanical ventilation are often necessary to maintain oxygenation and ventilation in the face of progressive pulmonary infiltrates and respiratory muscle fatigue. This intervention follows the ABC (Airway, Breathing, Circulation) prioritization framework, where securing the airway and supporting breathing is the immediate step before addressing other issues. Analysis of Other Options - Obtain a 12-lead ECG to rule out myocardial infarction: While chest pain and tachycardia could suggest a cardiac event, obtaining an ECG is a diagnostic, not a therapeutic, intervention. In a patient with severe hypoxemia and hypotension, delaying oxygenation and ventilatory support to perform an ECG is dangerous. The clinical picture, including fever and known acute leukemia, strongly points to DS, which can cause pericardial effusions and myocardial dysfunction, but the immediate priority is stabilizing the airway and breathing [1]. - Administer prescribed anxiolytic medication for anxiety: The patient’s anxiety is a physiological response to hypoxemia and air hunger, not a primary psychiatric condition. Administering an anxiolytic could depress the respiratory drive, worsening hypoxemia and potentially precipitating respiratory arrest. Treating the underlying cause of the anxiety—the profound hypoxia—is the correct intervention. - Check the patient's complete blood count and coagulation studies: Laboratory studies are important for confirming the diagnosis and guiding ongoing management, including the administration of corticosteroids, which are the mainstay of DS treatment [1]. However, they do not address the immediate threat to the patient’s airway and breathing. This action is secondary to stabilizing the patient’s respiratory status. Pathophysiology and Clinical Connection Differentiation syndrome occurs when agents like all-trans retinoic acid (ATRA) or arsenic trioxide trigger the rapid maturation of leukemic blasts. This process unleashes a cascade of pro-inflammatory cytokines, leading to endothelial damage and systemic capillary leak syndrome. The lungs are a primary target, resulting in alveolar flooding and severe ventilation-perfusion mismatch, which explains the rapid drop in oxygen saturation [1]. Concurrently, fluid extravasation into the pleural and pericardial spaces, combined with systemic vasodilation, leads to the hypotension and tachycardia observed. The nurse must recognize this constellation of symptoms not as an infection or isolated cardiac event, but as a single, rapidly progressive oncologic emergency where early, aggressive respiratory support is the pivotal life-saving measure [1].References (research sources) - [1]Identification and Management of Differentiation Syndrome in Emergency Settings: A Narrative Review.Research articleChang GA, Bey T, Stroh J, Qdaisat A, Yeung SJ. (2026) · DOI: 10.3390/cancers18111798 ## 임상 시나리오 Differentiation Syndrome: Emergency ManagementPrioritizing Airway and Breathing in Acute Leukemia Suspect differentiation syndrome in any patient with acute leukemia who develops acute dyspnea, fever, and hypotension. The pathophysiology involves a systemic inflammatory response with capillary leak, leading to non-cardiogenic pulmonary edema and respiratory failure. The immediate nursing priority is to support oxygenation and ventilation. Administer high-flow oxygen to target SpO2 above 92% and prepare for emergency intubation. Simultaneously, notify the provider and prepare to administer dexamethasone as prescribed. CautionDo not delay respiratory support for diagnostic tests like ECG or labs. Avoid anxiolytics and sedatives that can depress respiratory drive before the airway is secured. Continuous monitoring for fluid overload and pericardial effusion is critical. ## 핵심 개념 - **Differentiation Syndrome** — A life-threatening complication of therapy for acute leukemia, characterized by fever, respiratory distress, pulmonary infiltrates, and hypotension due to systemic inflammation and capillary leak. - **Capillary Leak Syndrome** — Increased permeability of capillaries causing fluid and protein to leak into interstitial spaces, leading to non-cardiogenic pulmonary edema, hypotension, and organ dysfunction. - **Priority Action** — In a rapidly deteriorating patient, nursing priority follows the ABC (Airway, Breathing, Circulation) framework, addressing the most immediate life-threatening condition first. - **Non-cardiogenic Pulmonary Edema** — Fluid accumulation in the lungs not caused by heart failure, but by damage to the alveolar-capillary membrane, as seen in differentiation syndrome. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old patient with acute lymphoblastic leukemia who was admit…](https://mymerci.kr/pages/nclex_q.php?qn_id=540756) - [A nurse is caring for a patient with acute lymphoblastic leukemia who suddenly develops se…](https://mymerci.kr/pages/nclex_q.php?qn_id=540757) - [A nurse is assessing a 58-year-old patient with acute myeloid leukemia who has been receiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=540758) - [A nurse is caring for a patient with acute lymphoblastic leukemia who develops tumor lysis…](https://mymerci.kr/pages/nclex_q.php?qn_id=540759) - [A nurse is caring for a patient with acute lymphoblastic leukemia who develops tumor lysis…](https://mymerci.kr/pages/nclex_q.php?qn_id=540760) - [A nurse is caring for a 45-year-old patient with acute lymphoblastic leukemia who received…](https://mymerci.kr/pages/nclex_q.php?qn_id=540761) - [A nurse is caring for a 35-year-old patient with Hodgkin lymphoma who reports progressive …](https://mymerci.kr/pages/nclex_q.php?qn_id=540763) - [A nurse is caring for a patient with acute leukemia who develops sudden onset of severe he…](https://mymerci.kr/pages/nclex_q.php?qn_id=540764) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._