# A nurse is caring for a 68-year-old patient with chronic heart failure who has been admitted with acute exacerbation. The patient presents with dyspnea, bilateral lower extremity edema, and jugular venous distension. Current vital signs: BP 90/60 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. The patient is receiving furosemide 40 mg IV BID and has a fluid restriction of 1500 mL/day. Which nursing intervention should the nurse prioritize first?

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> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 68-year-old patient with chronic heart failure who has been admitted with acute exacerbation. The patient presents with dyspnea, bilateral lower extremity edema, and jugular venous distension. Current vital signs: BP 90/60 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. The patient is receiving furosemide 40 mg IV BID and has a fluid restriction of 1500 mL/day. Which nursing intervention should the nurse prioritize first?

## 보기

1. Administer the next scheduled dose of furosemide immediately
2. Increase the patient's fluid restriction to 1000 mL/day
3. Encourage the patient to ambulate to improve circulation
4. Apply supplemental oxygen and position the patient in high Fowler's position **✔ 정답**

**정답: 4**

## 해설

The priority is to address acute respiratory distress and hypoxemia with oxygen and positioning, as these directly support ABCs (airway, breathing, circulation). Other interventions like diuretics or fluid restriction are important but secondary to immediate oxygenation needs.

## 심화 해설

Understanding the Priority: Airway, Breathing, Circulation

In any acute care scenario, the nursing process demands a rapid assessment based on the ABCs (Airway, Breathing, Circulation). For a patient with an acute exacerbation of chronic heart failure, the immediate threat is often respiratory compromise. This patient’s presentation with dyspnea, a respiratory rate of 28/min, and critically, an oxygen saturation of 88% on room air, signals a state of hypoxemic respiratory failure. The body’s compensatory mechanism, reflected by the tachycardia (HR 110 bpm), is a direct response to this inadequate oxygenation. Before addressing fluid volume overload with diuretics or adjusting long-term management plans, the nurse’s first and most critical action is to correct the life-threatening hypoxemia.

Why Oxygen and Positioning Are the First Priority

The physiological rationale is rooted in the relationship between ventilation, perfusion, and cardiac workload. In right ventricular failure, which is often a component of an acute heart failure exacerbation, the heart’s ability to pump blood through the pulmonary circulation is compromised [1]. When a patient with this condition also becomes hypoxemic, it triggers pulmonary vasoconstriction, further increasing the afterload against which the struggling right ventricle must pump. This creates a vicious cycle of worsening cardiac function and respiratory distress. By applying supplemental oxygen, you directly reverse the hypoxic pulmonary vasoconstriction, reducing the strain on the right ventricle. Positioning the patient in high Fowler’s position is a simultaneous, non-pharmacological intervention that uses gravity to reduce venous return to the heart and maximize lung expansion, immediately decreasing the work of breathing and improving gas exchange. This dual intervention directly targets the “B” in the ABCs of emergency care, stabilizing the patient’s most immediate physiological crisis [1].

Why Other Interventions Are Deferred

While the other options are components of the patient’s overall care plan, they are not the immediate priority in the context of acute decompensation. Administering the next scheduled dose of furosemide addresses the fluid overload causing the edema and jugular venous distension, but its diuretic effect is not instantaneous and does not correct the present hypoxemia. Similarly, increasing fluid restriction is a management strategy for preventing future exacerbations, not for treating an acute drop in oxygen saturation. Encouraging ambulation is contraindicated in a patient with unstable vital signs, severe dyspnea, and a blood pressure of 90/60 mmHg, as it would dangerously increase myocardial oxygen demand and risk a syncopal event [1]. The immediate goal is to stabilize oxygenation and reduce cardiac workload, which then creates a safer window for administering medications like furosemide.References (research sources)

- [1]Pulmonary Arterial Hypertension Emergency Complications and Evaluation: Practical Guide for the Advanced Practice Registered Nurses in the Emergency Department.Research articleHohsfield R, Archer-Chicko C, Housten T, Harris Nolley S. (2018) · DOI: 10.1097/tme.0000000000000210

## 임상 시나리오

Acute Heart Failure ExacerbationPrioritizing ABCs in Hypoxemic Respiratory Distress
For a patient with acute dyspnea and SpO2 88% on room air, the immediate nursing priority is to correct life-threatening hypoxemia using the ABC framework. Apply supplemental oxygen and position in High Fowler's to maximize lung expansion.

Hypoxemia triggers hypoxic pulmonary vasoconstriction, which increases right ventricular afterload and worsens heart failure. Reversing hypoxia breaks this cycle and reduces cardiac workload before administering diuretics like furosemide.

CautionDo not prioritize ambulation or fluid restriction changes in an acutely decompensating patient. Ambulation increases oxygen demand, and fluid restriction adjustments are not immediate life-saving measures.

## 핵심 개념

- **ABC Framework** — Airway, Breathing, Circulation; a systematic approach to prioritize life-saving interventions where oxygenation and ventilation needs are addressed before circulatory issues.
- **Hypoxemic Respiratory Failure** — A condition of inadequate gas exchange resulting in low blood oxygen levels (PaO2 < 60 mmHg or SpO2 < 90%), often indicated by dyspnea and tachycardia.
- **High Fowler's Position** — A sitting position with the head of the bed elevated to 60-90 degrees, which maximizes chest expansion and lung capacity to reduce dyspnea.
- **Hypoxic Pulmonary Vasoconstriction** — A compensatory mechanism where low alveolar oxygen triggers constriction of pulmonary vessels, increasing right ventricular afterload and worsening heart failure.
- **Jugular Venous Distension (JVD)** — Visible bulging of the jugular veins in the neck, a classic sign of increased central venous pressure often associated with right-sided heart failure and fluid overload.

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