# 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=543634 > 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? The nurse receives report on four patients at the beginning of the shift and must prioritize care. ## 보기 1. A 45-year-old patient with diabetes mellitus who is scheduled for discharge today and needs final medication teaching. 2. A 28-year-old patient with asthma who is experiencing increased shortness of breath and has an oxygen saturation of 88% on room air. **✔ 정답** 3. A 65-year-old patient with hypertension who is complaining of a mild headache and requests pain medication. 4. A 52-year-old patient with chronic kidney disease who has missed one dialysis session and is asking about rescheduling. **정답: 2** ## 해설 The asthmatic patient with shortness of breath and O2 sat 88% requires first assessment due to acute respiratory compromise. Other patients have non-urgent needs (discharge teaching, mild headache, dialysis question). ## 심화 해설 Prioritization Using the ABC Framework The nurse must apply the ABC (Airway, Breathing, Circulation) prioritization framework, a foundational principle for determining which patient requires immediate assessment. This framework directs the nurse to address life-threatening physiological needs before attending to stable or chronic conditions. The patient with asthma experiencing increased shortness of breath and an oxygen saturation of 88% on room air has a critical breathing compromise. This represents an acute deterioration in the "B" component of the ABCs, placing the patient at immediate risk for respiratory failure. Pathophysiological Rationale for Acute Respiratory Distress In an acute asthma exacerbation, bronchoconstriction, airway inflammation, and mucus plugging lead to severe ventilation-perfusion (V/Q) mismatch. An oxygen saturation of 88% indicates significant hypoxemia, reflecting a state where the lungs cannot effectively oxygenate the blood. This is a critical finding because prolonged hypoxemia leads to tissue hypoxia, metabolic acidosis, and ultimately, cardiac dysrhythmia or arrest. The concept of first-pass success in managing a failing airway or breathing, as highlighted in emergency intubation literature, underscores the urgency of early, effective intervention to prevent a cascade of complications . Delaying assessment risks progression to a state requiring emergent tracheal intubation, a procedure with inherent risks that increase with patient decompensation. Applying Clinical Evidence to the Prioritization Decision The immediate need for respiratory support is supported by evidence on managing acute respiratory failure. While the scoping review on non-invasive ventilation (NIV) focuses on a structured, protocol-driven approach for hypercapnic respiratory failure, the core principle is the timely recognition and treatment of respiratory distress to prevent further decline . The patient with an oxygen saturation of 88% is exhibiting a failure of basic oxygenation, the most fundamental step in the respiratory process. This patient’s need for immediate assessment and potential intervention, such as supplemental oxygen or bronchodilator therapy, supersedes the needs of the other patients. The patient with diabetes requiring discharge teaching (a psychosocial and knowledge need), the patient with hypertension and a mild headache (a comfort and chronic management need), and the patient with CKD who missed dialysis (a chronic management need with potential for future, but not immediate, life-threatening complications) are all clinically stable in this moment. The acute, life-threatening nature of the respiratory distress makes this patient the clear priority for the nurse's first assessment . ## 임상 시나리오 Acute Asthma Exacerbation: Immediate AssessmentApplying the ABC Framework for Respiratory Distress A patient with asthma and increased shortness of breath with an SpO2 of 88% on room air has a critical breathing compromise. This is the highest priority per the ABC framework. An SpO2 below 90% indicates severe hypoxemia. Immediate interventions include applying oxygen, administering bronchodilators, and preparing for potential escalation. CautionDo not delay assessment for stable patients. Discharge teaching, mild pain, and missed dialysis are secondary to an acute, life-threatening respiratory event. ## 핵심 개념 - **ABC Prioritization** — A triage framework where Airway, Breathing, and Circulation problems are addressed before other needs, as they represent immediate threats to life. - **Hypoxemia** — An abnormally low concentration of oxygen in the blood, clinically defined by reduced oxygen saturation (SpO2) or partial pressure of oxygen (PaO2). - **Ventilation-Perfusion (V/Q) Mismatch** — An imbalance between the amount of air reaching the alveoli (ventilation) and the amount of blood flowing to the alveoli (perfusion), impairing gas exchange. ## 같은 주제 문제 - [A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted to the…](https://mymerci.kr/pages/nclex_q.php?qn_id=543619) - [A 55-year-old patient with chronic heart failure is admitted to the medical unit with acut…](https://mymerci.kr/pages/nclex_q.php?qn_id=543620) - [A nurse is caring for a 68-year-old patient with chronic heart failure who was admitted wi…](https://mymerci.kr/pages/nclex_q.php?qn_id=543621) - [A nurse is caring for a 68-year-old patient with chronic heart failure who has been admitt…](https://mymerci.kr/pages/nclex_q.php?qn_id=543622) - [A 72-year-old patient with a history of ischemic cardiomyopathy is admitted to the medical…](https://mymerci.kr/pages/nclex_q.php?qn_id=543623) - [A 58-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted with a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543624) - [A nurse is caring for a 68-year-old patient with acute exacerbation of chronic obstructive…](https://mymerci.kr/pages/nclex_q.php?qn_id=543625) - [A 55-year-old patient with chronic heart failure is admitted to the medical unit with acut…](https://mymerci.kr/pages/nclex_q.php?qn_id=543626) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._