# A nurse is caring for a patient with a confirmed pulmonary embolism who is receiving anticoagulant therapy. Which nursing intervention should be the highest priority?

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## 문제

A nurse is caring for a patient with a confirmed pulmonary embolism who is receiving anticoagulant therapy. Which nursing intervention should be the highest priority?

## 보기

1. Monitor oxygen saturation continuously and administer supplemental oxygen as needed
2. Assess for signs of bleeding and monitor coagulation studies regularly
3. Position the patient in high Fowler's position and encourage deep breathing exercises **✔ 정답**
4. Educate the patient about activity restrictions and fall prevention measures

**정답: 3**

## 해설

For a patient with a confirmed PE, the highest priority according to the ABCs (Airway, Breathing, Circulation) framework is optimizing respiratory function. Positioning the patient in high Fowler's position and encouraging deep breathing immediately maximizes lung expansion, decreases the work of breathing, and improves oxygenation. While monitoring for bleeding risks associated with anticoagulant therapy is essential, it is secondary to addressing the acute and life-threatening respiratory compromise..

## 심화 해설

Understanding the Priority: Airway, Breathing, and Circulation (ABCs)

In the NCLEX-RN framework, when a patient presents with an acute condition like a pulmonary embolism (PE), the nursing process must always begin with the ABCs (Airway, Breathing, Circulation). While all the listed interventions are essential components of care for a patient on anticoagulation, the highest priority is the intervention that directly addresses a life-threatening physiological derangement. In PE, the primary pathophysiological problem is a ventilation-perfusion (V/Q) mismatch caused by an obstructed pulmonary artery. This obstruction impedes blood flow to functional alveoli, preventing proper gas exchange and leading to acute hypoxemia. The 2026 AHA/ACC guideline emphasizes a structured approach to immediate management based on clinical severity, which inherently prioritizes stabilization of oxygenation and hemodynamics [1]. Therefore, positioning the patient to optimize ventilation and perfusion mechanics is the most immediate, independent nursing action to mitigate this mismatch.

Rationale for the Correct Answer (Option 3)

Positioning the patient in high Fowler's position and encouraging deep breathing exercises directly targets the compromised respiratory function. High Fowler's position facilitates maximal chest expansion and reduces the pressure of the abdominal organs on the diaphragm, thereby decreasing the work of breathing. Encouraging deep breathing and coughing helps to expand atelectatic alveoli and mobilize secretions, which can further improve gas exchange in the unaffected lung segments. This intervention is a non-pharmacological, immediate nursing action that can be implemented without delay to improve the patient's oxygenation status, aligning with the guideline's focus on initial stabilization based on clinical severity assessment [1].

Analysis of Incorrect Options

Option 1 (Monitor oxygen saturation and administer supplemental oxygen) is a critical intervention, but it is a collaborative and supportive measure that follows the primary assessment and positioning. While the guideline supports oxygen therapy to maintain normoxia, the nurse can first optimize ventilation mechanics through positioning, which may reduce the oxygen requirement and is a foundational step before or alongside applying oxygen [1].

Option 2 (Assess for signs of bleeding and monitor coagulation studies) is a crucial safety intervention for a patient on anticoagulant therapy, as highlighted by the guideline's emphasis on balancing thrombotic and bleeding risks. However, this addresses a potential complication of the treatment, not the immediate, life-threatening hypoxemia caused by the embolism itself. In the acute phase, ensuring adequate oxygenation takes precedence over monitoring for a therapeutic side effect [1].

Option 4 (Educate the patient about activity restrictions and fall prevention) is an important long-term safety measure to prevent bleeding from trauma while on anticoagulation. However, patient education is a lower priority in the acute, unstable phase of care when the patient is experiencing a physiological crisis. The immediate need is to stabilize the patient's respiratory status, as reflected in the guideline's structured approach to acute management [1].References (research sources)

- [1]2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.GuidelineWriting Committee Members, Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN. (2026) · DOI: 10.1161/cir.0000000000001415

## 임상 시나리오

PE: Immediate Nursing PriorityApplying the ABC Framework to Pulmonary Embolism
For a patient with an acute pulmonary embolism, the highest priority intervention targets the primary problem: a V/Q mismatch causing hypoxemia. Position the patient in High Fowler's to maximize chest expansion and reduce diaphragmatic pressure, directly improving ventilation mechanics.

Encourage deep breathing and coughing exercises to expand atelectatic alveoli and mobilize secretions. This independent nursing action addresses the Breathing component of the ABCs before adjunctive oxygen or medication monitoring.

CautionWhile anticoagulation safety and bleeding assessments are critical, they address potential complications. In the acute phase, an intervention that immediately mitigates life-threatening respiratory compromise takes precedence over monitoring for treatment side effects.

## 핵심 개념

- **Ventilation-Perfusion (V/Q) Mismatch** — An imbalance in lung ventilation and blood flow, where pulmonary artery obstruction in PE prevents blood from reaching ventilated alveoli, impairing gas exchange and causing hypoxemia.
- **High Fowler's Position** — An upright sitting position with the head of the bed elevated to 90 degrees, which maximizes chest expansion and reduces diaphragmatic pressure to decrease work of breathing.
- **ABC Priority Framework** — A nursing assessment and intervention model that prioritizes Airway, Breathing, and Circulation as the most immediate life-sustaining needs in an acute care setting.

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