# A nurse is caring for a client diagnosed with empyema. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541316 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client diagnosed with empyema. Which nursing intervention should be the priority? ## 보기 1. Monitor respiratory status and oxygen saturation continuously **✔ 정답** 2. Administer prescribed pain medications as needed 3. Encourage deep breathing exercises every 2 hours 4. Maintain strict intake and output documentation **정답: 1** ## 해설 Continuous monitoring of respiratory status and oxygen saturation is the priority for empyema to detect rapid respiratory compromise and prevent failure. Other interventions like pain management and breathing exercises are secondary. ## 심화 해설 Priority Intervention for Empyema Correct Answer: 1. Monitor respiratory status and oxygen saturation continuously Empyema is the accumulation of purulent fluid within the pleural space, which directly compromises lung expansion and impairs gas exchange. The primary pathophysiological concern is respiratory compromise due to the space-occupying collection compressing the lung parenchyma. Therefore, the immediate nursing priority is to assess and ensure adequate oxygenation and ventilation, which aligns with the airway, breathing, and circulation (ABC) framework fundamental to NCLEX-RN prioritization. Continuous monitoring of respiratory status and oxygen saturation allows the nurse to detect early signs of deterioration, such as increasing tachypnea, use of accessory muscles, or declining SpO₂. A chest tube (thoracostomy) is the definitive treatment to drain the infected fluid and restore negative intrapleural pressure, as described by Merkle et al. [1]. The chest tube system, which includes a water seal chamber, works to re-expand the lung by removing fluid and air. The effectiveness of this intervention is directly evaluated through ongoing respiratory assessment; a sudden change in respiratory status could indicate a life-threatening complication such as a tension pneumothorax or a dislodged or occluded chest tube [1]. While systemic infection and inflammation are present in empyema, the immediate threat to life is hypoxemia from the mechanical compression of the lung, not the infection itself. The other options represent important but secondary aspects of care. Administering pain medication (Option 2) is crucial for comfort and to facilitate deep breathing, but pain is not an immediately life-threatening condition. Encouraging deep breathing exercises (Option 3) aids in lung re-expansion and secretion clearance, yet this intervention is ineffective and potentially harmful if the patient is in acute respiratory distress. Maintaining strict intake and output (Option 4) is a standard component of monitoring fluid balance, especially in the context of infection, but it does not address the critical, immediate risk of respiratory failure. The prognostic value of inflammatory markers like C-reactive protein (CRP) in empyema has been studied for mortality risk, but this reflects a longer-term assessment of treatment response rather than the moment-to-moment monitoring required for a patient with an active pleural space infection . References (research sources) - [1]Care of a Chest TubeResearch articleMerkle A, Lobo CM, Cindass R. (2026) ## 임상 시나리오 Empyema Nursing PriorityApplying the ABC Framework to Pleural Infection For a client with empyema, the accumulation of pus in the pleural space causes lung compression and directly impairs gas exchange. The immediate threat to life is hypoxemia, not infection or pain. Prioritize interventions using the ABC framework. Continuous monitoring of respiratory status (rate, depth, accessory muscle use) and oxygen saturation allows for early detection of deterioration, such as a drop in SpO₂ below 90%. The definitive treatment is a chest tube (thoracostomy) to drain the fluid. The effectiveness of this drainage is evaluated by the same ongoing respiratory assessment. A sudden change in status could signal a life-threatening complication like a tension pneumothorax or tube dislodgement. CautionDo not delegate a comprehensive respiratory assessment for an unstable empyema patient. While pain control and deep breathing are important, they are secondary to ensuring the airway and breathing are stable. ## 핵심 개념 - **Empyema** — Accumulation of purulent fluid in the pleural space, compressing the lung and impairing gas exchange. - **ABC Framework** — A prioritization model in nursing (Airway, Breathing, Circulation) used to identify and manage the most life-threatening conditions first. - **Thoracostomy (Chest Tube)** — A surgical procedure to insert a tube into the pleural space to drain fluid, air, or pus, restoring negative pressure and allowing lung re-expansion. - **Water Seal Chamber** — A component of the chest drainage system that acts as a one-way valve, allowing air and fluid to exit the pleural space without re-entering. - **Hypoxemia** — An abnormally low concentration of oxygen in the arterial blood, a primary concern in empyema due to impaired lung function. ## 같은 주제 문제 - [A nurse is assessing a 58-year-old patient with a 2-week history of worsening chest pain, …](https://mymerci.kr/pages/nclex_q.php?qn_id=541312) - [A 45-year-old patient with a history of pneumonia is being assessed for suspected empyema.…](https://mymerci.kr/pages/nclex_q.php?qn_id=541313) - [A nurse is caring for a 72-year-old client with empyema who has a chest tube connected to …](https://mymerci.kr/pages/nclex_q.php?qn_id=541314) - [A nurse is caring for a 30-year-old client with empyema who has just had a chest tube inse…](https://mymerci.kr/pages/nclex_q.php?qn_id=541315) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._