# A nurse is caring for a patient with Goodpasture's syndrome who is experiencing progressive kidney dysfunction and pulmonary hemorrhage. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540856 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with Goodpasture's syndrome who is experiencing progressive kidney dysfunction and pulmonary hemorrhage. Which nursing intervention should be the priority? ## 보기 1. Encourage increased fluid intake to prevent dehydration 2. Position the patient in Trendelenburg position to improve circulation 3. Administer high-dose vitamin supplements to boost immunity 4. Monitor respiratory status and maintain patent airway **✔ 정답** **정답: 4** ## 해설 In Goodpasture's syndrome, pulmonary hemorrhage is life-threatening, so monitoring respiratory status and maintaining a patent airway is the priority to ensure oxygenation. Other options address supportive care but do not address the immediate respiratory risk. ## 심화 해설 Understanding the Priority in Goodpasture's Syndrome The question presents a patient with Goodpasture's syndrome, an autoimmune disorder characterized by the production of antibodies that attack the basement membrane in the kidneys and lungs. This leads to a classic clinical picture of rapidly progressive glomerulonephritis and pulmonary hemorrhage. When prioritizing nursing care, the ABC (Airway, Breathing, Circulation) framework is the foundational guide. Why Airway and Breathing Take Precedence The immediate threat to life in a patient with an active pulmonary hemorrhage is a compromised airway and impaired gas exchange. Bleeding into the alveoli directly obstructs the interface for oxygen and carbon dioxide exchange, which can rapidly lead to hypoxemic respiratory failure. This is a more acute and life-threatening concern than the kidney dysfunction, which, while severe, typically progresses over a longer timeframe. The nursing priority is therefore to continuously monitor respiratory status—including rate, depth, breath sounds, oxygen saturation, and signs of increased work of breathing—and to actively maintain a patent airway. This involves positioning the patient to optimize ventilation (typically upright), having suction equipment ready, and being prepared to support oxygenation. Analysis of Incorrect Options The other options do not address the most immediate life threat and are not the priority interventions for this specific condition: - Option 1 (Encourage increased fluid intake): While fluid management is a consideration in kidney dysfunction, aggressive fluid intake is not a priority and could be harmful. In the context of oliguric renal failure, fluid is often restricted to prevent volume overload, hypertension, and pulmonary edema, which would further compromise respiratory status. - Option 2 (Position in Trendelenburg position): The Trendelenburg position (head down, feet elevated) is used for hypotensive shock, not for respiratory distress. For a patient with pulmonary hemorrhage, this position would worsen breathing by pushing abdominal contents against the diaphragm and could increase the risk of aspiration. The correct position is typically upright or semi-Fowler's to maximize lung expansion. - Option 3 (Administer high-dose vitamin supplements): Goodpasture's syndrome is an autoimmune disease, not a nutritional deficiency or an immune-compromised state that would benefit from vitamin supplementation as a priority treatment. The core management involves plasmapheresis to remove the pathogenic antibodies and immunosuppressive therapy, not boosting immunity, which could theoretically exacerbate the autoimmune attack. Connecting to NCLEX Clinical Judgment This question tests the ability to recognize and act on a life-threatening complication using the ABC framework. The presence of "pulmonary hemorrhage" in the scenario is the critical cue that elevates airway and breathing management to the highest priority. The nurse must differentiate between a chronic, progressive problem (kidney dysfunction) and an acute, potentially fatal event (active bleeding in the lungs). The immediate nursing action is a focused respiratory assessment and ensuring a clear airway, which forms the basis for all subsequent medical interventions like oxygen therapy, mechanical ventilation, or emergent plasmapheresis. ## 임상 시나리오 Goodpasture Syndrome: Acute PriorityManaging Pulmonary Hemorrhage The immediate priority for a patient with Goodpasture's syndrome and active pulmonary hemorrhage is to secure the airway and support breathing. Hemorrhage into the alveoli directly obstructs gas exchange, leading to rapid hypoxemic respiratory failure. Continuously monitor respiratory status: rate, depth, breath sounds, and oxygen saturation. Position the patient upright to optimize ventilation and have suction equipment immediately available to maintain a patent airway. CautionDo not place the patient in a Trendelenburg position, as this can worsen respiratory distress by increasing pressure on the diaphragm and raising intracranial pressure. Kidney dysfunction, while serious, is a secondary concern to the immediate threat of airway compromise. ## 핵심 개념 - **Goodpasture's syndrome** — Autoimmune disorder with antibodies attacking basement membranes in kidneys and lungs, causing glomerulonephritis and pulmonary hemorrhage. - **ABC framework** — Prioritization model in nursing: Airway, Breathing, Circulation; used to identify the most immediate life-threatening condition. - **Pulmonary hemorrhage** — Bleeding into the lung alveoli, impairing gas exchange and potentially causing airway obstruction and hypoxemic respiratory failure. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old male client who was admitted with suspected Goodpasture…](https://mymerci.kr/pages/nclex_q.php?qn_id=540853) - [A nurse is assessing a 28-year-old male patient admitted with suspected Goodpasture's synd…](https://mymerci.kr/pages/nclex_q.php?qn_id=540854) - [A nurse is caring for a client with Goodpasture's syndrome who is experiencing hemoptysis …](https://mymerci.kr/pages/nclex_q.php?qn_id=540855) - [A nurse is caring for a patient with Goodpasture's syndrome who is experiencing progressiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=540857) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._