# A nurse is assessing a 68-year-old patient admitted with suspected pneumonia. Which assessment finding would be the MOST concerning and require immediate intervention?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541285  
> language: ko  
> subject: Adult Health

## 문제

A nurse is assessing a 68-year-old patient admitted with suspected pneumonia. Which assessment finding would be the MOST concerning and require immediate intervention?

## 보기

1. Temperature of 101.5°F (38.6°C) with productive cough containing yellow-green sputum
2. Oxygen saturation of 88% on room air with use of accessory muscles for breathing **✔ 정답**
3. Blood pressure of 110/70 mmHg with heart rate of 95 beats per minute
4. Complaints of pleuritic chest pain rated 6/10 that worsens with deep inspiration

**정답: 2**

## 해설

Oxygen saturation of 88% with accessory muscle use indicates severe hypoxemia and impending respiratory failure, requiring immediate oxygen therapy and monitoring. Other findings (fever, cough, normal vitals, pleuritic pain) are typical of pneumonia but not immediately life-threatening.

## 심화 해설

Clinical Judgment
This question evaluates Prioritization and Recognizing Clinical Deterioration. You must identify the finding that represents the most immediate life threat in a pneumonia patient. The correct answer is the Notify HCP! status of SpO2 88% and use of accessory muscles. This indicates impending Acute Respiratory Failure and is a Critical Cue. According to the ABC principle, where Airway and Breathing take priority over Circulation, this has the highest priority.

Memory Tip:
**A**irway & **B**reathing First! **S**pO2

## 임상 시나리오

Clinical Practice Guide
When assessing a pneumonia patient, systematically evaluate the Respiratory Status: check oxygen saturation (SpO2), respiratory rate, breathing pattern (use of accessory muscles, orthopnea), skin color, and level of consciousness.
Caution:
In SATA (Select All That Apply) questions, if instructed to choose the "MOST urgent" item, you must select only one. Do not confuse this with questions asking to select all "abnormal" findings.

## 핵심 개념

- **Hypoxemia (저산소혈증)** — A condition where the partial pressure of oxygen (PaO2) or oxygen saturation (SpO2) in arterial blood is abnormally low. It generally means SpO2
- **Accessory Muscle Use (보조호흡근 사용)** — A phenomenon where, during breathing, muscles such as the supraclavicular muscles, sternocleidomastoid muscles, and abdominal muscles are used in addition to the normal diaphragm and intercostal muscles. This is an objective sign of increased work of breathing and dyspnea, suggesting impending respiratory failure.
- **Pleuritic Pain (흉막성 통증)** — Pain caused by inflammation of the pleura (the thin membrane covering the lungs and chest wall). It is characterized by a sharp, stabbing pain during breathing, coughing, or sneezing.
- **Productive Cough (생산적 기침)** — Cough with sputum (phlegm). This is a common symptom that appears during infections (such as bacterial pneumonia) or airway inflammation.
- **Oxygen Saturation (SpO2) (산소포화도)** — The percentage of hemoglobin bound to oxygen as measured by a pulse oximeter. Normal is 95-100%, and less than 90% indicates moderate to severe hypoxemia.

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