# A 45-year-old patient with atrial fibrillation, chronic liver disease, and a history of falls is admitted with confusion and weakness. Current medications include warfarin, spironolactone, and lactulose. Laboratory results show: INR 3.5, creatinine 1.2 mg/dL, BUN 20 mg/dL, and potassium 3.8 mEq/L. Vital signs are: BP 130/80 mmHg, HR 85 bpm, RR 18/min, O2 sat 95% on room air. What is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543642  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A 45-year-old patient with atrial fibrillation, chronic liver disease, and a history of falls is admitted with confusion and weakness. Current medications include warfarin, spironolactone, and lactulose. Laboratory results show: INR 3.5, creatinine 1.2 mg/dL, BUN 20 mg/dL, and potassium 3.8 mEq/L. Vital signs are: BP 130/80 mmHg, HR 85 bpm, RR 18/min, O2 sat 95% on room air. What is the nurse's priority action?

## 보기

1. Administer prescribed insulin to manage hyperglycemia
2. Provide respiratory support and positioning **✔ 정답**
3. Prepare to administer IV diuretics for fluid overload
4. Monitor cardiac rhythm due to hyperkalemia

**정답: 2**

## 해설

Priority is addressing potential respiratory compromise with oxygen therapy and positioning per ABC principles, as the patient presents with confusion and weakness. Other options manage hyperglycemia, fluid overload, or hyperkalemia, which are less immediate threats based on the given data.

## 심화 해설

Clinical Judgment
This question assesses the ability to prioritize when a patient with multiple chronic conditions experiences an acute deterioration. The core is identifying the most immediate life threat. Synthesizing the patient's vital signs and lab results, Notify HCP! The hypoxemia (O2 sat 88%) from acute heart failure exacerbation is the most urgent problem. According to the ABC (Airway, Breathing, Circulation) principle, breathing (B) and oxygenation take priority over all other issues (hyperglycemia, hyperkalemia, fluid overload). Oxygen therapy and elevating the head of the bed are immediate interventions to relieve pulmonary edema and improve gas exchange.

Memory Tip:
**A**lways **B**reathing **C**omes **F**irst! In heart failure patients, ABC (Breathing) is always first. Hypoxemia requires immediate intervention, while hyperglycemia or borderline hyperkalemia allows for some time.

KR vs US:
The ABC priority principle applies identically in both Korea and the US. The difference is that in US NGN scenarios, when selecting a 'hypothetical intervention,' you are often required to choose the most appropriate priority action without any mention of an order being 'ready.' In this question as well, addressing the breathing problem is the top priority regardless of whether an order exists.

## 임상 시나리오

Clinical Practice Guide
The priorities of nursing care for patients with acute heart failure exacerbation are as follows:
1.  Breathing & Oxygenation: Assess for hypoxemia and initiate oxygen therapy, elevate the head of the bed to 45-90 degrees.
2.  Hemodynamic Monitoring: Continuously monitor vital signs and oxygen saturation.
3.  Medication Preparation: Prepare to administer IV diuretics, vasodilators, etc., as prescribed.
4.  Metabolic Abnormality Management: Monitor and manage hyperglycemia and electrolyte imbalances (hyperkalemia).

Caution:
A common pitfall in SATA (Select All That Apply) questions is selecting all interventions that seem "correct." However, in questions asking for the "single highest priority" action, the action that addresses a directly life-threatening ABC issue is always the priority. Hyperkalemia or hyperglycemia are important but less urgent than respiratory arrest.

## 핵심 개념

- **Hypoxemia (저산소혈증)** — A condition where the oxygen level in arterial blood is abnormally low. It generally means an oxygen saturation (SpO2) below 90%, and in this case, it was 88%. Immediate oxygen therapy is required.
- **Acute Heart Failure Exacerbation (급성 심부전 악화)** — A condition in which symptoms and signs suddenly worsen in patients with chronic heart failure. Dyspnea, tachypnea, hypoxemia, and fluid overload symptoms (edema) may occur.
- **Hyperkalemia (고칼륨혈)** — Serum potassium concentration elevated above the normal range (usually 3.5-5.0 mEq/L). It commonly occurs in CKD patients and can alter myocardial cell excitability, leading to life-threatening arrhythmias.
- **Chronic Kidney Disease (CKD, 만성 신장질환)** — A condition in which kidney function progressively and irreversibly declines. Stage 3 indicates moderate kidney damage (GFR 30-59 mL/min), with risks of electrolyte imbalances and altered diuretic response.
- **Pulmonary Edema (폐부종)** — Abnormal accumulation of fluid in the pulmonary interstitial tissue and alveoli. A major complication of worsening heart failure, it impairs gas exchange, causing dyspnea and hypoxemia.

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