# A nurse is caring for a patient with a confirmed pulmonary embolism who is experiencing acute dyspnea and chest pain. Which nursing action should be the highest priority?

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## 문제

A nurse is caring for a patient with a confirmed pulmonary embolism who is experiencing acute dyspnea and chest pain. Which nursing action should be the highest priority?

## 보기

1. Obtain a detailed history of recent travel and immobilization
2. Administer high-flow oxygen and prepare for emergency interventions **✔ 정답**
3. Perform a comprehensive physical assessment including lung sounds
4. Educate the patient about anticoagulation therapy risks and benefits

**정답: 2**

## 해설

Administering high-flow oxygen and preparing for emergencies addresses immediate life-threatening hypoxemia in suspected PE. Assessment and education are important but secondary to stabilizing the patient.

## 심화 해설

Clinical Priority Setting in Acute Pulmonary Embolism

When a patient with a confirmed pulmonary embolism presents with acute dyspnea and chest pain, the nurse must immediately apply the Airway, Breathing, Circulation (ABC) framework to identify the highest priority intervention. The patient's symptoms indicate a critical mismatch between ventilation and perfusion (V/Q mismatch), leading to profound hypoxemia.

The formalized expert recommendations for the initial assessment of respiratory distress emphasize that the very first step in management is to assess and support oxygenation and ventilation, as hypoxemia is the most immediate threat to life [1]. Administering high-flow oxygen directly addresses the "Breathing" component of the ABCs by attempting to correct the hypoxemia that is causing the patient's acute distress. Simultaneously preparing for emergency interventions, such as notifying the rapid response team or preparing for potential advanced airway management and administration of thrombolytics, is a critical parallel action that anticipates the rapid deterioration these patients can experience. This dual action of immediate support and proactive preparation is the cornerstone of emergency nursing care for a life-threatening condition.

While the other options represent important aspects of comprehensive nursing care, they are not the highest priority in the acute, unstable phase. Obtaining a detailed history of travel and immobilization is a secondary assessment task that helps confirm risk factors but does not address the patient's immediate physiological crisis. A comprehensive physical assessment, including lung sounds, is part of a focused respiratory assessment but must be performed rapidly and should never delay life-saving interventions like oxygen administration. Patient education about anticoagulation therapy is a crucial long-term goal for preventing recurrence, but it is inappropriate and unsafe to prioritize teaching when the patient is in severe physiological distress and their safety is compromised. The immediate priority is to stabilize the patient's oxygenation and hemodynamic status, guided by the structured, evidence-based approach to respiratory distress [1].References (research sources)

- [1]Guidelines for the Initial Assessment of Respiratory Distress in the Emergency Department.GuidelineLe Borgne P, Thille AW, Guenezan J, Aissaoui N, Boureau AS, Bally C, Balen F, Basset A, Bilbault P, Boissier F, Claessens YE, Decavèle M, Diehl JL, Douillet D, Guillon A, Hausfater P, Javaudin F, Jezequel M, Kuteifan K, L'Her E, Marjanovic N, Maury E, Ohana M, Pichereau C, Ray P, Reuter PG, Tiberti N, Voiriot G, Yordanov Y, Le Conte P, Terzi N. (2026) · DOI: 10.1016/j.aicoj.2025.100005

## 임상 시나리오

Acute PE: Emergency Priority SettingApplying the ABC Framework to a Life-Threatening Embolism
The immediate threat in a confirmed pulmonary embolism with acute dyspnea is hypoxemia from V/Q mismatch. The highest priority action is to administer high-flow oxygen to support breathing while simultaneously preparing for emergency interventions like thrombolytics or rapid response.

Clinical AlertDo not delay oxygen therapy for a comprehensive assessment or history-taking. A patient’s rapid deterioration into respiratory failure is a greater immediate risk than missing historical details. Keep the patient in a high Fowler’s position and stay prepared for advanced airway management.

## 핵심 개념

- **V/Q Mismatch** — An imbalance between alveolar ventilation and pulmonary capillary blood flow, causing hypoxemia, as seen when a clot blocks perfusion to ventilated alveoli.
- **ABC Framework** — A prioritization method in emergency care: Airway, Breathing, Circulation. It dictates that life-threatening breathing problems like hypoxemia are managed before secondary assessments.
- **High-Flow Oxygen** — Delivery of oxygen at concentrations sufficient to correct hypoxemia, often via a non-rebreather mask, which is the first-line intervention for acute respiratory distress.

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