# A nurse is caring for a patient with fluid volume excess. Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542673 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a patient with fluid volume excess. Which nursing intervention should be the highest priority? ## 보기 1. Encourage increased oral fluid intake to promote kidney function 2. Position the patient in Trendelenburg position to improve circulation 3. Administer oxygen therapy at 2L/min via nasal cannula 4. Elevate the head of the bed to 45 degrees and monitor respiratory status **✔ 정답** **정답: 4** ## 해설 Elevating the head of the bed to 45 degrees and monitoring respiratory status is the highest priority to reduce cardiac workload and improve oxygenation in fluid volume excess. Other interventions are inappropriate or lower priority. ## 심화 해설 Understanding the Priority: Fluid Volume Excess and Respiratory Compromise In a patient with fluid volume excess (FVE), the primary pathophysiological concern is the accumulation of fluid in the vascular and interstitial spaces, which can lead to life-threatening complications. The highest priority assessment and intervention must follow the ABC (Airway, Breathing, Circulation) framework. As fluid overload progresses, it increases hydrostatic pressure, forcing fluid into the pulmonary alveoli and causing pulmonary edema. This directly impairs gas exchange, making respiratory status the most critical and immediate concern. The randomized controlled trial by de Souza Maciel Ferreira et al. (2025) confirms that targeted nursing interventions for fluid volume control are essential to improving physiological outcomes in patients with this diagnosis [1]. Furthermore, the case report by Liang et al. (2026) illustrates how acute fluid shifts can rapidly precipitate respiratory distress, necessitating immediate interventions to reduce cardiac preload and support breathing [2]. Analysis of Options Why Option 4 is the Highest Priority Elevating the head of the bed to 45 degrees is an immediate, independent nursing action that reduces venous return to the heart (preload) and lowers diaphragmatic pressure, which eases the work of breathing. Simultaneously monitoring respiratory status allows for the early detection of deterioration, such as the development of crackles, increased respiratory rate, or decreasing oxygen saturation. This directly addresses the "Breathing" component of the ABCs, which is the most likely to be acutely compromised in FVE, as evidenced by the rapid onset of dyspnea and respiratory distress in fluid overload scenarios [2]. Why Other Options are Incorrect - Option 1: Encouraging increased oral fluid intake is contraindicated and dangerous in a patient with fluid volume excess. The core problem is hypervolemia; adding more fluid will worsen the overload, increase the risk of pulmonary edema, and exacerbate the patient's condition. The nursing intervention studied by de Souza Maciel Ferreira et al. focuses on controlling fluid volume, not increasing it [1]. - Option 2: Positioning the patient in Trendelenburg (head down) position is contraindicated in fluid volume excess and any condition with respiratory compromise. This position shifts abdominal contents against the diaphragm, further restricting lung expansion, and increases venous return to an already overloaded heart, potentially worsening pulmonary congestion. - Option 3: Administering oxygen is an important supportive measure for hypoxia resulting from pulmonary edema, but it is not the highest priority independent nursing intervention. The nurse must first optimize the patient's position to improve ventilation and gas exchange. Furthermore, applying oxygen is a dependent or collaborative intervention requiring a provider's order, whereas elevating the head of the bed is an independent action that can be performed immediately upon recognizing respiratory distress. The case by Liang et al. (2026) highlights that managing the underlying fluid shift and respiratory mechanics is paramount, with pharmacological support like diuretics and sedatives following initial stabilization [2].References (research sources) - [1]Effect of the fluid management nursing intervention on improving biochemical test results and dialysis therapy in chronic kidney disease patients: a randomized controlled trial.RCT/clinical trialde Souza Maciel Ferreira JE, de Sousa DF, Moreira RP, Morais HCC, Barros LM, Cavalcante TF. (2025) · DOI: 10.17533/udea.iee.v43n3e12 - [2]Acute pulmonary edema secondary to magnesium sulfate tocolysis in twin pregnancy: a case report.Case reportLiang X, Kang J, Zheng B, Liao Y, Wang S, Yan G, Jia J. (2026) · DOI: 10.1515/crpm-2025-0029 ## 임상 시나리오 Clinical Scenario A 72-year-old patient with a history of heart failure presents with acute dyspnea, bilateral crackles on auscultation, and 3+ pitting edema in the lower extremities. Vital signs show BP 160/95 mmHg, HR 110 bpm, RR 28/min, and SpO2 88% on room air. The nurse suspects fluid volume excess leading to pulmonary edema. Priority Nursing Actions - **Immediate Positioning:** Elevate the head of the bed to a high Fowler's position (45-60 degrees) to immediately reduce venous return to the heart and lower diaphragmatic pressure. This independent nursing action can rapidly alleviate dyspnea. - **Respiratory Assessment:** Perform a focused respiratory assessment including auscultation of lung sounds, monitoring respiratory rate, depth, and use of accessory muscles, and continuous pulse oximetry to detect deterioration. - **Oxygen Administration:** Apply supplemental oxygen as ordered to maintain SpO2 above 92%, titrating based on patient response. Prepare for non-invasive positive pressure ventilation (e.g., BiPAP) if respiratory distress persists. - **Hemodynamic Monitoring:** Monitor blood pressure, heart rate, and urine output closely. Assess for jugular vein distension and changes in edema to evaluate response to interventions. - **Medication Preparation:** Anticipate orders for loop diuretics (e.g., furosemide) to reduce fluid volume, vasodilators (e.g., nitroglycerin) to decrease preload and afterload, and morphine for anxiety and dyspnea relief. Clinical Reasoning In fluid volume excess with respiratory compromise, the nurse’s first priority is to support breathing and reduce cardiac workload. Positioning the patient upright is a rapid, low-risk intervention that directly addresses the ABCs. This aligns with evidence showing that nursing interventions targeting fluid control and respiratory support significantly improve outcomes in acute decompensation. Continuous reassessment is critical to determine if the patient requires escalation to advanced airway management or intensive care. ## 핵심 개념 - **Fluid Volume Excess** — A state of increased isotonic fluid retention in the extracellular space, often leading to edema, hypertension, and pulmonary congestion. - **Pulmonary Edema** — Accumulation of fluid in the lung alveoli due to increased hydrostatic pressure, impairing gas exchange and causing severe respiratory distress. - **ABC Priority Framework** — A systematic approach in emergency care prioritizing Airway, Breathing, and Circulation; guides immediate nursing interventions for life-threatening conditions. - **Preload** — The volume of blood in the ventricles at the end of diastole; reducing preload via positioning decreases the workload of the heart and pulmonary congestion. - **Semi-Fowler's Position** — A position where the head of the bed is elevated to 30-45 degrees, used to facilitate breathing and reduce cardiac workload in patients with respiratory or cardiac issues. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected fluid volume excess. 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