# A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess first?

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> subject: Next Gen NCLEX

## 문제

A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess first?

## 보기

1. A 45-year-old patient with diabetes mellitus who is requesting pain medication for a headache rated 6 on a 0 to 10 scale
2. A 68-year-old patient with chronic obstructive pulmonary disease (COPD) who is using accessory muscles to breathe and has an SpO2 of 88% **✔ 정답**
3. A 52-year-old patient with hypertension who is complaining of nausea and has a blood pressure of 160/100 mmHg
4. A 38-year-old patient post-appendectomy (day 2) who is asking for assistance to ambulate to the bathroom

**정답: 2**

## 해설

The patient with COPD using accessory muscles and SpO2 88% shows respiratory distress, a life-threatening emergency requiring immediate assessment per ABC principles. Other patients have non-urgent needs like pain management or ambulation assistance.

## 심화 해설

Priority Setting Using the ABC Framework

The nurse must prioritize the patient with the most immediate threat to airway, breathing, or circulation. The patient with chronic obstructive pulmonary disease (COPD) who is using accessory muscles and has an SpO2 of 88% is demonstrating signs of acute respiratory distress and hypoxemia, which takes precedence over pain, elevated blood pressure with nausea, or routine postoperative needs.

Pathophysiology and Clinical Reasoning

In a patient with COPD, an acute exacerbation (AECOPD) leads to worsened airflow limitation and gas trapping. This increases the work of breathing, and the body recruits accessory muscles—such as the sternocleidomastoid and scalene muscles—to try to maintain adequate ventilation. The use of these muscles is a critical clinical sign indicating that the patient is in severe respiratory distress and at risk of impending respiratory muscle fatigue and failure [1].

The SpO2 reading of 88% indicates significant hypoxemia. In the context of acute respiratory failure, hypoxemia is associated with high mortality if not promptly corrected [2]. The body’s compensatory mechanisms are failing, and without immediate intervention—such as optimizing oxygenation delivery, which evidence suggests may include modalities like high-flow nasal cannula or non-invasive ventilation for severe cases—the patient can rapidly decompensate [2]. This represents a clear "Breathing" problem in the ABC (Airway, Breathing, Circulation) priority framework, which is always the highest priority after securing an airway.

Analysis of Other Options

- Option 1 (Pain): A headache rated 6/10 is a comfort issue. While pain management is an important nursing responsibility, it is not life-threatening and can be safely delayed until the patient with respiratory distress is stabilized.

- Option 3 (Elevated BP with Nausea): A blood pressure of 160/100 mmHg with nausea is concerning and requires follow-up, as it could indicate hypertensive urgency or other complications. However, this is a "Circulation" issue that, while serious, is not as immediately critical as an active "Breathing" compromise where the patient’s compensatory mechanisms are visibly failing.

- Option 4 (Postoperative Ambulation): A request for assistance to ambulate on postoperative day 2 is a routine safety and activity need. It is the lowest priority among the presented scenarios.

Application of Evidence to Nursing Assessment

For the nurse, the assessment must go beyond just looking at the SpO2 number. The combination of a low oxygen saturation and the physical sign of accessory muscle use is a powerful indicator of increased work of breathing and physiological decompensation in AECOPD. Research on perioperative hypoxemia management emphasizes that early identification and intervention for respiratory deterioration are crucial for preventing adverse outcomes . The nurse’s immediate priority is to assess this patient first, apply oxygen as prescribed, position the patient to maximize ventilation (e.g., high Fowler’s position), and promptly notify the healthcare provider for further orders, which may include bronchodilators, corticosteroids, or escalation to non-invasive ventilatory support. This aligns with the goal of preventing progression to overt respiratory failure, a condition with a complex and unpredictable clinical course in advanced COPD .References (research sources)

- [1]Severity-adapted graded exercise rehabilitation reduces systemic inflammation and improves functional capacity in hospitalized AECOPD: an assessor-blinded randomized controlled trial.RCT/clinical trialZeng H, Chen Y, Ran H, Zhao D, Wang Y, Fu D, Yang N, Luo J, Ma L, Hu Q, Huang L, Li C, Luo L, Liu R. (2026) · DOI: 10.3389/fphys.2026.1767608

- [2]Comparing high-flow nasal cannula oxygen and non-invasive ventilation to standard oxygenation in non-selected intensive care unit patients admitted for acute hypoxaemic respiratory failure: protocol for the KISS (Key oxygenation Interventions in Surgical and non-Surgical patients) adaptive randomised controlled trial.RCT/clinical trialJaber S, Huguet H, Molinari N, De Jong A. (2025) · DOI: 10.1136/bmjopen-2025-100149

## 임상 시나리오

Prioritizing a COPD Patient in Respiratory DistressApplying the ABC Framework to Nursing Assessment
The ABC framework dictates that a Breathing problem takes priority. A patient with COPD using accessory muscles and an SpO2 of 88% is in acute respiratory distress, signaling potential respiratory muscle fatigue and failure.

Immediate nursing actions include assessing lung sounds, ensuring a patent airway, and optimizing oxygenation. Prepare for interventions like high-flow nasal cannula or non-invasive ventilation as ordered. A pain complaint, elevated blood pressure, or routine ambulation are lower priorities.

CautionDo not delay intervention for an SpO2 of 88% in a patient with increased work of breathing. This severe hypoxemia can rapidly lead to decompensation and cardiac arrest if not promptly corrected.

## 핵심 개념

- **Chronic Obstructive Pulmonary Disease** — A group of chronic respiratory diseases (chronic bronchitis, emphysema) characterized by airflow limitation. The main symptoms are shortness of breath, cough, and sputum.
- **Accessory Muscle Use** — Using muscles not normally involved in breathing (e.g., sternocleidomastoid, trapezius) for respiration. This indicates increased work of breathing and is an important sign of dyspnea/respiratory failure.
- **Oxygen Saturation** — The measured value of the proportion of hemoglobin bound to oxygen in arterial blood. The normal range is 95-100%, and less than 90% suggests hypoxemia.
- **Respiratory Distress** — A painful condition caused by respiratory failure. Signs include use of accessory muscles, cyanosis, tachypnea, and anxiety, requiring immediate medical intervention.
- **Clinical Acuity / Prioritization** — Determining the order of nursing care based on the severity of the patient's condition. The ABC (airway, breathing, circulation) principle and the degree of life threat are the most common criteria.

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