# A 75-year-old patient with diabetes mellitus, chronic kidney disease (CKD) stage 3, and heart failure is admitted with acute exacerbation of heart failure. The patient presents with shortness of breath, bilateral lower extremity edema, and blood glucose of 280 mg/dL. Which nursing action should be the highest priority?

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## 문제

A 75-year-old patient with diabetes mellitus, chronic kidney disease (CKD) stage 3, and heart failure is admitted with acute exacerbation of heart failure. The patient presents with shortness of breath, bilateral lower extremity edema, and blood glucose of 280 mg/dL. Which nursing action should be the highest priority?

## 보기

1. Administer prescribed insulin to lower blood glucose levels
2. Elevate the head of the bed and apply oxygen therapy
3. Assess respiratory status and initiate diagnostic evaluation **✔ 정답**
4. Restrict fluid intake and monitor daily weights

**정답: 3**

## 해설

Priority assessment focuses on the most life-threatening condition. Respiratory compromise from acute heart failure exacerbation requires immediate evaluation (assess respiratory status and obtain ABG) before interventions. Other options address important but less urgent needs.

## 심화 해설

Clinical Priority Setting in Acute Heart Failure Exacerbation

The patient presents with a classic triad of acute decompensated heart failure (ADHF): dyspnea, bilateral lower extremity edema, and significant hyperglycemia (280 mg/dL) on a background of diabetes, chronic kidney disease (CKD) stage 3, and heart failure. When multiple systems are involved, the nurse must apply the ABC (Airway, Breathing, Circulation) framework to identify the most immediate threat to life.

Why Option 3 is the Highest Priority

Assessing respiratory status and initiating diagnostic evaluation directly addresses the "B" (Breathing) component of the ABCs. The patient's shortness of breath is the most acute and potentially life-threatening symptom, indicating possible pulmonary edema from fluid overload. Before any intervention can be safely and effectively implemented, the nurse must first gather critical data. This includes evaluating breath sounds, respiratory rate, oxygen saturation, and work of breathing. Initiating a diagnostic evaluation, such as a chest X-ray or arterial blood gas, provides objective data to confirm the clinical suspicion and guide subsequent therapy. In the context of heart failure, a structured approach to assessment is foundational. Research on home-based fluid management in chronic heart failure patients demonstrates that effective symptom monitoring and management strategies are directly correlated with reduced symptom burden over time [1]. This underscores that the initial step in any care setting, especially an acute exacerbation, is a thorough assessment to understand the patient's current physiological state before acting.

Analysis of Other Options

- Option 1: While a blood glucose of 280 mg/dL requires management, hyperglycemia is not an immediate threat to the patient's airway or breathing. The respiratory distress from acute heart failure takes precedence. Addressing the glucose level is an important but secondary action.

- Option 2: Elevating the head of the bed and applying oxygen are critical interventions for respiratory distress. However, they are actions that follow the assessment. The nurse must first assess the patient's respiratory status to determine the appropriate oxygen delivery device and flow rate. Implementing an intervention without a preceding focused assessment is a violation of the nursing process.

- Option 4: Fluid restriction and daily weight monitoring are core components of long-term heart failure management. The concept of home fluid management, which includes monitoring weight and fluid intake, is vital for preventing rehospitalization and managing symptom burden in the vulnerable post-discharge phase [1]. However, during an acute exacerbation presenting with severe dyspnea, these are not the priority actions. They are part of the ongoing management plan that is initiated after the patient's immediate respiratory status is stabilized.

The nursing process mandates that assessment comes first. In an acute situation, a focused respiratory assessment to confirm the nature and severity of the breathing problem is the foundational step upon which all other interventions are built.References (research sources)

- [1]Latent transition analysis of home-based fluid management during the vulnerable phase in patients with chronic heart failure: impact on symptom burden.Research articleZhang J, Cai Y, Li X, Song Q, Sun X, Yang J, Yu H. (2026) · DOI: 10.3389/fcvm.2026.1811019

## 임상 시나리오

Prioritizing Assessment in Acute DyspneaABC Framework for Decompensated Heart Failure
When a patient with acute decompensated heart failure presents with shortness of breath, the immediate priority is to assess the respiratory status. The nurse must gather data on breath sounds, respiratory rate, oxygen saturation, and work of breathing before any intervention.

Initiate a diagnostic evaluation such as a chest X-ray or arterial blood gas to confirm pulmonary edema and guide therapy. This structured assessment is foundational to safe and effective management.

CautionDo not delay assessment to implement interventions like oxygen therapy or positioning. The nursing process mandates that a focused assessment precedes action, especially when the airway or breathing is compromised.

## 핵심 개념

- **ABC Framework** — A systematic approach to clinical priority setting that addresses Airway, Breathing, and Circulation in order of immediate threat to life.
- **Acute Decompensated Heart Failure (ADHF)** — A sudden worsening of heart failure symptoms, such as dyspnea and edema, often due to fluid overload, requiring urgent medical assessment and intervention.
- **Pulmonary Edema** — A condition caused by excess fluid in the lungs, often a complication of heart failure, leading to severe shortness of breath and impaired gas exchange.
- **Nursing Process (Assessment)** — The first and foundational step of the nursing process, involving the systematic collection of data to identify a patient's health status before planning or implementing care.

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