# A nurse is caring for multiple patients during a busy shift. Which patient should the nurse assess first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543570  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for multiple patients during a busy shift. Which patient should the nurse assess first?

## 보기

1. A 68-year-old patient with chronic heart failure who reports sudden onset of severe shortness of breath **✔ 정답**
2. A 45-year-old patient with diabetes mellitus who has a blood glucose level of 250 mg/dL and reports increased thirst
3. A 72-year-old patient with pneumonia who has a temperature of 101.2°F (38.4°C) and productive cough with green sputum
4. A 55-year-old patient with hypertension who has a blood pressure reading of 168/94 mmHg and reports mild headache

**정답: 1**

## 해설

Priority assessment focuses on life-threatening conditions. The patient with heart failure and sudden severe shortness of breath indicates acute exacerbation like pulmonary edema or MI, requiring immediate intervention. Other patients have stable or less urgent issues.

## 심화 해설

Prioritization Using the ABC Framework

When prioritizing care for multiple patients, the nurse must use a systematic approach such as the airway, breathing, circulation (ABC) framework. This method directs the nurse to first address the patient with the most immediate threat to life. While all the patients presented require nursing intervention, the patient with a sudden onset of severe shortness of breath has a problem that directly compromises the "B" (breathing) component of this framework, making them the highest priority.

Analysis of the Correct Answer

Option 1 describes a patient with chronic heart failure who reports a sudden onset of severe shortness of breath. This clinical presentation is a red flag for acute decompensated heart failure, a condition that can rapidly progress to respiratory failure. The word "sudden" indicates an acute change in the patient's baseline, which is a critical finding. The underlying pathophysiology involves the heart's inability to pump effectively, leading to a rapid backup of fluid into the pulmonary vasculature (pulmonary edema). This severely impairs gas exchange, creating a life-threatening situation. As highlighted in the provided evidence on pulmonary embolism, a patient with an acute pulmonary process "can deteriorate quickly" . Similarly, a patient with acute decompensated heart failure can present with profound dyspnea and hypoxemia, requiring immediate assessment and intervention to prevent cardiorespiratory arrest. The nurse must assess this patient first to evaluate their respiratory status, oxygen saturation, and lung sounds, and to initiate lifesaving measures like high-flow oxygen, positioning, and diuretic therapy.

Analysis of Incorrect Answers

Option 2 presents a patient with diabetes mellitus, a blood glucose of 250 mg/dL, and increased thirst. These findings are consistent with hyperglycemia. While this requires timely intervention with insulin and fluid management, the condition is not immediately life-threatening in the same way as an acute respiratory compromise. The patient's airway and breathing are not acutely at risk, making this a lower priority than Option 1.

Option 3 describes a patient with pneumonia, a fever of 101.2°F (38.4°C), and a productive cough. These are expected clinical manifestations of an infectious process. The patient's condition requires ongoing monitoring, antipyretics, and antibiotics, but it represents a stable, albeit active, clinical picture. There is no indication of an acute change or severe respiratory distress, such as shortness of breath, that would signal an immediate threat to the airway or breathing.

Option 4 presents a patient with a hypertensive urgency, indicated by a blood pressure of 168/94 mmHg and a mild headache. This condition requires blood pressure management and monitoring, typically with oral antihypertensives. However, in the absence of acute target organ damage (such as a hypertensive emergency with encephalopathy, stroke, or acute pulmonary edema), it does not take priority over a patient with an acute and severe breathing problem. The evidence from a case of delayed STEMI illustrates that severe cardiac dysfunction can lead to "cardiogenic shock" and "end-stage heart failure" , underscoring that a sudden breathing change in a heart failure patient is a potential precursor to such a catastrophic decline and must be the nurse's first concern.

## 임상 시나리오

Prioritizing Acute Dyspnea in Heart FailureApplying the ABC Framework for Immediate Assessment
A report of sudden onset severe shortness of breath in a patient with chronic heart failure is a critical sign of acute decompensated heart failure and potential pulmonary edema. This directly compromises the Breathing component of the ABC framework, making it the highest priority.

Immediate nursing actions include assessing oxygen saturation, breath sounds (for crackles), and vital signs. Administer oxygen to maintain SpO2 above 92%, position the patient upright, and prepare for interventions like diuretics and non-invasive ventilation.

CautionAn acute change in baseline is a red flag. A patient with acute pulmonary edema can deteriorate rapidly to respiratory failure. Do not delay assessment for other tasks; this is a life-threatening emergency.

## 핵심 개념

- **Chronic Heart Failure** — Chronic heart failure. A chronic condition in which the heart's pumping function is reduced, failing to supply enough blood to meet the metabolic demands of the body's tissues.
- **Dyspnea** — Shortness of breath. A subjective symptom of feeling breathless or having difficulty breathing. It is an important sign of heart or lung disease.
- **Pulmonary Edema** — Pulmonary edema. A condition in which fluid abnormally accumulates in the interstitial tissue of the lungs and within the alveoli, commonly occurring during worsening heart failure and potentially causing rapid respiratory failure.
- **Hyperglycemia** — Hyperglycemia. A condition where the glucose concentration in the blood is higher than the normal range. It is a major characteristic of diabetes.
- **Hypertension** — Hypertension. A condition where blood pressure is persistently above the normal range. It is a major cardiovascular risk factor.

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