# A nurse is caring for a client with asthma who is experiencing an acute exacerbation. The client's oxygen saturation is 88% on room air, respiratory rate is 28/min, and the client is using accessory muscles for breathing. Which nursing intervention should the nurse implement first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541278 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with asthma who is experiencing an acute exacerbation. The client's oxygen saturation is 88% on room air, respiratory rate is 28/min, and the client is using accessory muscles for breathing. Which nursing intervention should the nurse implement first? ## 보기 1. Administer bronchodilator medication via nebulizer 2. Apply low-flow oxygen therapy via nasal cannula **✔ 정답** 3. Position the client in high Fowler's position 4. Encourage the client to perform pursed-lip breathing **정답: 2** ## 해설 The priority is to correct hypoxemia with low-flow oxygen (2 L/min via nasal cannula) to maintain SpO₂ 88-92% in COPD, as severe hypoxemia poses immediate risk. Other interventions are important but secondary after oxygenation is stabilized. ## 심화 해설 Understanding the Clinical Scenario The client is experiencing an acute asthma exacerbation with an oxygen saturation of 88% on room air, tachypnea at 28/min, and increased work of breathing evidenced by accessory muscle use. These findings indicate significant hypoxemia and airway obstruction. In an acute exacerbation, bronchoconstriction, airway inflammation, and mucus plugging lead to ventilation-perfusion (V/Q) mismatch, impairing gas exchange and reducing arterial oxygen levels. The immediate physiological threat is hypoxemia, which can lead to tissue hypoxia, cardiac dysrhythmias, and respiratory failure if not promptly corrected. Prioritizing Interventions Using the ABC Framework The NCLEX-RN exam consistently tests the ability to prioritize care using the Airway, Breathing, Circulation (ABC) framework. In this scenario, the airway is partially compromised by bronchoconstriction, but the most critical and immediately life-threatening component is the severe hypoxemia, which falls under "Breathing." While all the listed interventions are appropriate for an asthma exacerbation, the nurse must determine which action addresses the most urgent physiological need first. Analysis of the Correct Answer: Apply Low-Flow Oxygen Therapy The correct initial intervention is to apply low-flow oxygen therapy via nasal cannula. The rationale is rooted in the immediate correction of hypoxemia. An SpO2 of 88% corresponds to a partial pressure of arterial oxygen (PaO2) of approximately 55 mmHg, which is dangerously low. Administering supplemental oxygen increases the fraction of inspired oxygen (FiO2), thereby improving the oxygen diffusion gradient across the alveolar-capillary membrane. This rapidly addresses the V/Q mismatch and prevents the cascade of complications from cellular hypoxia. A standardized, evidence-based approach to acute asthma management, as highlighted in institutional care guidelines, emphasizes the early and systematic assessment and correction of hypoxemia to stabilize the patient before or concurrently with other therapies [1]. The implementation of such guidelines has been shown to standardize care processes and can influence clinical outcomes by ensuring that critical first steps, like oxygen therapy for hypoxemia, are not delayed [1]. Why Other Options Are Not the First Priority - Option 1: Administer bronchodilator medication via nebulizer. While a bronchodilator is a cornerstone treatment for reversing bronchoconstriction, its effect is not immediate. It takes time for the medication to be aerosolized, inhaled, and to bind to beta-2 receptors on bronchial smooth muscle to cause relaxation. During this lag time, the client’s severe hypoxemia persists and may worsen. Oxygen therapy can be initiated in seconds and begins to correct the life-threatening problem instantly. The nurse can and should administer the bronchodilator immediately after applying oxygen. - Option 3: Position the client in high Fowler's position. Positioning the client upright optimizes lung expansion by reducing pressure from the abdominal organs on the diaphragm and allowing the accessory muscles to work more efficiently. This is a helpful and non-invasive intervention, but it does not directly address the profound oxygen deficit. Like bronchodilator administration, it is a rapid intervention that can be performed concurrently with or immediately after the application of oxygen, but it is not the singular priority over correcting hypoxemia. - Option 4: Encourage the client to perform pursed-lip breathing. Pursed-lip breathing is a technique that creates back pressure in the airways, preventing premature airway collapse during exhalation and helping to expel trapped air. It is highly effective for managing dyspnea and improving gas exchange in stable COPD or during mild asthma episodes. However, during a severe acute exacerbation with marked hypoxemia and accessory muscle use, the client is in significant distress and may not be able to coordinate this technique effectively. It is not the first-line intervention for a rapid, critical drop in oxygen saturation. The immediate priority is to provide passive oxygen support. Connecting to Guideline-Based Care The decision to prioritize oxygen aligns with the structured, protocol-driven care described in asthma management guidelines. An institutional asthma care guideline emphasizes a systematic approach to acute exacerbations, which inherently begins with a rapid assessment of severity—including oxygenation—and the immediate initiation of supportive therapies to stabilize the patient [1]. The goal of such guidelines is to reduce variability in care and ensure that critical, evidence-based interventions are delivered promptly, which can positively impact clinical outcomes [1]. The nurse’s first action of applying oxygen to a hypoxemic patient is a direct application of this principle, ensuring that the most fundamental physiological need is met before proceeding with other pharmacologic and non-pharmacologic treatments.References (research sources) - [1]Implementation of an Institutional Asthma Care Guideline in Hospitalized Children: Effects on Clinical Outcomes and Healthcare Resource Utilization.GuidelineIntusup S, Ruangnapa K, Anuntaseree W, Saelim K, Prasertsan P, Sirianansopa K. (2026) · DOI: 10.2147/jaa.s605374 ## 임상 시나리오 Prioritizing Care in Acute Asthma ExacerbationImmediate intervention for the hypoxemic patient In an acute asthma exacerbation, the ABC (Airway, Breathing, Circulation) framework guides initial actions. When a patient presents with an SpO2 of 88%, the most immediate threat is hypoxemia under the 'Breathing' component. The first intervention is to apply low-flow oxygen therapy via nasal cannula to correct the oxygen deficit. This directly addresses the risk of tissue hypoxia and cardiac dysrhythmias before other treatments. CautionDo not delay oxygen administration to administer a bronchodilator or position the patient. While these are appropriate, oxygen delivery is the priority when the patient is severely hypoxemic. Monitor the patient's response closely, titrating oxygen to maintain an SpO2 of 92% or higher. ## 핵심 개념 - **Hypoxemia** — Low oxygen level in the blood, indicated by an SpO2 below 90%. - **ABC Framework** — A prioritization model in nursing: Airway, Breathing, Circulation, used to identify and manage life-threatening conditions first. - **Accessory Muscle Use** — A sign of increased work of breathing where muscles in the neck, chest, and abdomen are used to assist respiration. - **V/Q Mismatch** — An imbalance between ventilation and perfusion in the lungs, impairing gas exchange, commonly seen in asthma exacerbations. - **Low-Flow Oxygen Therapy** — Delivery of oxygen at a rate that does not meet the patient's entire inspiratory demand, typically via nasal cannula. ## 같은 주제 문제 - [A nurse is assessing a 72-year-old patient with chronic obstructive pulmonary disease (COP…](https://mymerci.kr/pages/nclex_q.php?qn_id=541276) - [A nurse is assessing a 68-year-old client with chronic obstructive pulmonary disease (COPD…](https://mymerci.kr/pages/nclex_q.php?qn_id=541277) - [A nurse is caring for a client with pneumonia who has been on continuous oxygen therapy at…](https://mymerci.kr/pages/nclex_q.php?qn_id=541279) - [A nurse is caring for a client with moderate COPD who has been admitted with an acute exac…](https://mymerci.kr/pages/nclex_q.php?qn_id=541280) - [A nurse is caring for a client with COPD who is experiencing an acute exacerbation. 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