# A nurse is caring for a client who is suspected of having a pulmonary embolism. Which nursing action should be the priority?

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## 문제

A nurse is caring for a client who is suspected of having a pulmonary embolism. Which nursing action should be the priority?

## 보기

1. Administer prescribed anticoagulant medication
2. Position the client in high Fowler's position and administer oxygen **✔ 정답**
3. Prepare the client for immediate CT pulmonary angiogram
4. Insert a large-bore IV catheter for emergency access

**정답: 2**

## 해설

The priority is to optimize oxygenation and ventilation by positioning in high Fowler's and administering oxygen, addressing the immediate life-threatening hypoxemia in suspected PE. Other interventions like anticoagulants or diagnostics are important but secondary to stabilizing respiration.

## 심화 해설

Understanding the Priority: Airway and Breathing First

When a pulmonary embolism (PE) is suspected, the immediate physiological threat is impaired gas exchange leading to hypoxemia. A PE obstructs pulmonary blood flow, creating a ventilation-perfusion (V/Q) mismatch. This means that while air reaches the alveoli, blood flow to carry that oxygen away is blocked, causing a rapid drop in blood oxygen levels. The body's compensatory mechanisms, such as increased heart rate and respiratory rate, can quickly decompensate. Therefore, the nurse's first action must directly address the life-threatening hypoxemia. Positioning the client in high Fowler's position maximizes lung expansion by reducing pressure from the abdominal organs on the diaphragm, while administering oxygen increases the concentration of oxygen in the available alveoli, improving diffusion into the bloodstream. This aligns with the core nursing principle of the ABCs (Airway, Breathing, Circulation), where oxygenation is the most time-sensitive intervention to prevent cardiac arrest. Evidence-based summaries for managing perioperative hypoxemia consistently identify immediate oxygen therapy as a foundational, high-priority intervention to correct dangerously low oxygen saturation [4].

Why Other Options Are Not the Immediate Priority

While all listed actions are important in the care of a client with a PE, they are secondary to stabilizing the client's respiratory status.

- Administer prescribed anticoagulant medication: Anticoagulation is the definitive medical treatment to prevent further clot formation and extension, but it does not address the existing clot or the immediate, critical hypoxemia. Its effect is not instantaneous; stabilizing oxygenation must occur first [4].

- Prepare the client for immediate CT pulmonary angiogram: A CT pulmonary angiogram is the gold standard for diagnosing a PE. However, sending a hemodynamically unstable, severely hypoxemic client to the radiology department is unsafe. The client must be stabilized with oxygen and positioning before any transport or diagnostic procedure occurs.

- Insert a large-bore IV catheter for emergency access: IV access is crucial for fluid resuscitation and medication administration. However, it falls under the "Circulation" component of the ABCs. A client who is not oxygenating will progress to cardiac collapse regardless of IV access. Breathing takes precedence over circulation in this acute presentation.

Connecting the Evidence to Clinical Practice

The priority of oxygenation is supported by evidence-based nursing concepts applied in acute chest pain scenarios. A study on continuous improvement in pre-examination processes for acute chest pain highlighted that optimizing the initial assessment and intervention stages—which includes immediate oxygen administration for hypoxemia—is critical for patient safety and effective management . The systematic approach to managing a suspected PE requires the nurse to first recognize and treat the clinical sign that poses the most immediate danger: a critically low oxygen saturation. The best evidence synthesis for managing hypoxemia reinforces that nursing interventions should be systematically prioritized, with airway management and oxygen delivery being the most urgent steps to prevent severe complications such as cardiac arrhythmias or respiratory failure [4]. Even in complex, high-mortality situations like an amniotic fluid embolism complicated by a pulmonary thromboembolism, the initial clinical focus is on supporting oxygenation and hemodynamics to manage the acute disturbance before definitive diagnostic or advanced therapeutic measures can be safely implemented .References (research sources)

- [4]Best Evidence Summary of Nursing Management for Perioperative Patients with Hypoxemia.Research articleLi G, Xiang J, Li J, Peng S, Cui X, Liu S. (2026) · DOI: 10.2147/jmdh.s598436

## 임상 시나리오

Suspected Pulmonary Embolism: Immediate Nursing PriorityApplying the ABC Framework to Life-Threatening Hypoxemia
A pulmonary embolism (PE) causes a ventilation-perfusion (V/Q) mismatch, where blood flow to oxygenated alveoli is obstructed. The immediate physiological threat is severe hypoxemia, which can rapidly lead to decompensation and cardiac arrest.

The first nursing action must be to position the client in high Fowler's position and administer oxygen. This directly targets the ABCs (Airway, Breathing, Circulation) by maximizing lung expansion and increasing the concentration of available oxygen to improve diffusion into the bloodstream.

Clinical AlertDo not delay oxygen therapy to obtain diagnostic tests like a CT pulmonary angiogram or to administer anticoagulants. Stabilizing respiratory status is the most time-sensitive intervention to prevent deterioration. Monitor for signs of respiratory failure and be prepared to escalate care.

## 핵심 개념

- **Ventilation-Perfusion (V/Q) Mismatch** — A condition where air reaches the alveoli but blood flow is blocked, preventing gas exchange and causing hypoxemia, as seen in a pulmonary embolism.
- **High Fowler's Position** — An upright sitting position at approximately 90 degrees that maximizes lung expansion by reducing pressure on the diaphragm from abdominal organs.
- **ABC Priority** — A nursing principle prioritizing Airway, Breathing, and Circulation, where immediate oxygenation interventions take precedence to prevent cardiac arrest.

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