# A nurse is caring for a patient with severe asthma who is experiencing an acute exacerbation. Which action should the nurse take first to ensure patient safety?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541274  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a patient with severe asthma who is experiencing an acute exacerbation. Which action should the nurse take first to ensure patient safety?

## 보기

1. Administer the prescribed bronchodilator via nebulizer
2. Position the patient in high Fowler's position
3. Assess the patient's oxygen saturation and respiratory status **✔ 정답**
4. Prepare for possible intubation and mechanical ventilation

**정답: 3**

## 해설

In acute asthma exacerbation, assessment (oxygen saturation and respiratory status) is the priority to determine severity and guide interventions, following ABC principles. Administering bronchodilators or preparing for intubation are important but secondary to initial assessment.

## 심화 해설

Clinical Reasoning and Prioritization in Acute Asthma Exacerbation

When a patient with severe asthma presents with an acute exacerbation, the immediate priority is to determine the severity of the attack to guide subsequent interventions. The nursing process mandates that assessment precedes all other actions, including implementation and evaluation. Therefore, the nurse’s first action must be to assess the patient's oxygen saturation and respiratory status.

While administering a bronchodilator, positioning the patient, and preparing for advanced airway management are all critical components of care, they are interventions that depend on the data gathered from a rapid, focused assessment. Without first evaluating the patient’s current oxygenation and work of breathing, the nurse cannot safely determine the most appropriate and urgent intervention. For instance, the decision to administer a nebulized bronchodilator versus preparing for intubation hinges entirely on the clinical picture obtained through immediate assessment.

The provided evidence underscores the critical nature of accurate assessment in respiratory distress. The Cochrane review protocol by Honda et al. highlights the complexity of managing asthma exacerbations by investigating the effectiveness of high-flow nasal cannula (HFNC) oxygen therapy compared to conventional therapy [1]. This research question itself is born from the assessment finding of persistent hypoxemia despite standard treatment, demonstrating that therapy is escalated based on continuous reassessment. A nurse cannot initiate or recommend an appropriate oxygen delivery device without first measuring and interpreting the patient’s oxygen saturation.

Furthermore, the case report by Yamada et al. provides a powerful clinical lesson on why a thorough initial and ongoing assessment is non-negotiable [2]. The report describes a patient with a known asthma diagnosis who developed acute wheezing and oxygen desaturation that did not respond to systemic corticosteroids. The eventual diagnosis was dysfunctional breathing (DB), a condition that can perfectly mimic an asthma exacerbation, even causing clinically significant hypoxemia. This case illustrates that assuming the cause of wheezing and desaturation is an asthma exacerbation without a careful assessment can lead to ineffective and potentially harmful treatments. The nurse’s initial assessment of respiratory pattern, breath sounds, and oxygen saturation is the first step in differentiating a true asthma exacerbation from other pathologies like DB, which would necessitate a completely different management approach. By prioritizing assessment, the nurse ensures patient safety by verifying the nature of the problem before acting.References (research sources)

- [1]High-flow nasal cannula oxygen therapy for asthma exacerbation.Research articleHonda A, Watanabe Y, Abe Y, Kusumoto S, Hasegawa T, Noma H, Ota E, Imai T, Yamaji N, Barroga E. (2025) · DOI: 10.1002/14651858.cd016205

- [2]Dysfunctional breathing mimicking asthma exacerbation with acute hypoxemia: a case report.Case reportYamada K, Hirai K, Mizuoka S, Mondori K, Akioka M, Sato K, Nagamine H, Matsumoto Y, Nakai T, Watanabe T, Asai K, Kawaguchi T. (2026) · DOI: 10.1016/j.rmcr.2026.102419

## 임상 시나리오

Acute Asthma Exacerbation: Initial AssessmentPrioritizing the Nursing Process for Patient Safety
The nurse's first action for a patient in acute respiratory distress is always a rapid, focused assessment. This includes evaluating oxygen saturation via pulse oximetry and observing the patient's respiratory status (rate, depth, use of accessory muscles, breath sounds).

All interventions, such as administering a bronchodilator or positioning, are based on the clinical data gathered. The assessment determines the severity of the exacerbation and guides the next most critical step, such as the need for immediate intubation preparation.

CautionDo not delay assessment to begin an intervention. A patient's condition can deteriorate rapidly, and treatment without a current assessment can be ineffective or harmful. The assessment must precede and guide all actions.

## 핵심 개념

- **Asthma Exacerbation** — Asthma exacerbation. A condition where asthma symptoms suddenly or gradually worsen, leading to difficulty breathing, coughing, wheezing, and chest tightness. May require emergency treatment.
- **Oxygen Saturation** — Oxygen saturation. An indicator representing the proportion of hemoglobin in the blood that is bound with oxygen. It is measured using a pulse oximeter, and normal is generally 95-100%. Below 90% suggests hypoxemia.
- **High Fowler's Position** — High Fowler's position. A sitting posture with the head of the bed elevated to 60-90 degrees. Used to maximize lung volume and assist the action of accessory respiratory muscles in patients with dyspnea.
- **Nebulizer** — Nebulizer. A device that sprays liquid medication into fine particles so the patient can inhale it. Commonly used to administer bronchodilators (e.g., albuterol) during acute asthma exacerbations.
- **Intubation** — Intubation. A procedure in which an endotracheal tube is inserted to maintain or protect the airway. It is performed on patients with severe respiratory failure, decreased consciousness, or airway obstruction.

## 같은 주제 문제

- [A nurse is assessing a 65-year-old patient with a history of chronic obstructive pulmonary…](https://mymerci.kr/pages/nclex_q.php?qn_id=541269)
- [A nurse is assessing a 28-year-old patient with a history of asthma who presents to the em…](https://mymerci.kr/pages/nclex_q.php?qn_id=541270)
- [A nurse is caring for a client with severe asthma who is experiencing an acute exacerbatio…](https://mymerci.kr/pages/nclex_q.php?qn_id=541271)
- [A nurse is caring for a 65-year-old client with COPD exacerbation and a history of asthma …](https://mymerci.kr/pages/nclex_q.php?qn_id=541272)
- [A nurse is caring for a client with severe asthma exacerbation who has been receiving cont…](https://mymerci.kr/pages/nclex_q.php?qn_id=541273)
- [A nurse is caring for a 28-year-old patient with severe asthma who presents to the emergen…](https://mymerci.kr/pages/nclex_q.php?qn_id=541275)
- [A 7-year-old child with asthma is brought to the emergency department by parents who repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=542488)
- [A 5-year-old child with asthma is brought to the emergency department by parents who repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=542489)

---

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

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