# Situation: A 78-year-old woman with pneumonia of the right lower lobe is admitted to the medical ward. She has no history of heart or kidney disease. She is receiving intravenous (IV) antibiotics and 0.9% sodium chloride at 125 mL/h. Her admission weight was 52.0 kg. Later that morning she becomes short of breath at rest and coughs up frothy sputum. While the physician is being called, in which position should the nurse place her?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629898  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 78-year-old woman with pneumonia of the right lower lobe is admitted to the medical ward. She has no history of heart or kidney disease. She is receiving intravenous (IV) antibiotics and 0.9% sodium chloride at 125 mL/h. Her admission weight was 52.0 kg.

Later that morning she becomes short of breath at rest and coughs up frothy sputum. While the physician is being called, in which position should the nurse place her?

## 보기

1. Left side with her head tilted down
2. Semi-Fowler position with her legs raised on pillows
3. Sitting upright with her legs down **✔ 정답**
4. Supine with both legs raised

**정답: 3**

## 해설

Dyspnea with frothy sputum after fluid excess signals pulmonary edema. Sitting upright with the legs dependent eases breathing and reduces venous return to the heart and lungs, while the nurse slows the infusion, gives oxygen as ordered, and notifies the physician.

## 심화 해설

Pathophysiology

The sudden onset of dyspnea at rest with frothy sputum in a patient receiving 125 mL/h of isotonic crystalloid points to acute pulmonary edema. In this older adult without known heart or kidney disease, the most likely trigger is fluid overload from rapid IV administration superimposed on age-related reductions in cardiac and renal reserve. Excess intravascular volume raises pulmonary capillary hydrostatic pressure, forcing protein-poor fluid across the alveolar–capillary membrane into the interstitial space and then the alveoli. When air mixes with this alveolar fluid, the classic pink, frothy sputum appears [1].

The immediate nursing priority is to reduce venous return to the right heart and lower pulmonary capillary pressure. Positioning is the fastest intervention available before the physician arrives.

Why Sitting Upright with Legs Dependent Works

Placing the patient sitting upright with her legs down produces two complementary effects. First, the upright posture expands the thoracic cavity and lowers the diaphragm, improving lung compliance and reducing the work of breathing. Second, gravity pools blood in the lower extremities, which decreases venous return to the right atrium. Less blood returning to the right heart means less blood delivered to the pulmonary circulation, thereby lowering pulmonary capillary pressure and reducing further fluid transudation into the alveoli [1].

| Position | Effect on Venous Return | Effect on Breathing | Appropriate for Pulmonary Edema? |
| --- | --- | --- | --- |
| Sitting upright, legs down | Decreased by gravity pooling in legs | Improved lung expansion | Yes — first action |
| Semi-Fowler with legs raised | Increased by leg elevation | Moderate improvement | No — worsens preload |
| Supine with legs raised | Markedly increased | Reduced lung expansion | No — contraindicated |
| Left side, head down | Variable, may increase | Impaired | No — used for air embolism, not pulmonary edema |

Key point! Leg elevation — whether in Semi-Fowler or supine — actively increases venous return and can worsen pulmonary congestion. In acute pulmonary edema, the legs must remain dependent, not elevated.

Immediate Nursing Actions While Awaiting the Physician

Positioning is only one part of the initial response. The nurse should simultaneously slow or stop the IV infusion to prevent further volume loading, administer oxygen as ordered to correct hypoxemia, and prepare for further interventions such as diuretics or vasodilators once the physician evaluates the patient [1]. Continuous monitoring of respiratory status, oxygen saturation, and urine output is essential because deterioration can occur rapidly.

Watch out! Do not confuse this presentation with pneumonia-related hypoxemia alone. The frothy sputum and acute onset after IV fluids distinguish pulmonary edema from worsening infection. Pneumonia may coexist, but the immediate life threat here is fluid overload, and positioning must target venous return reduction first.References (research sources)

- [1]Acute pulmonary oedema.Research articlePowell J, Graham D, O'Reilly S, Punton G (2016) · DOI: 10.7748/ns.30.23.51.s47

## 임상 시나리오

Acute Pulmonary Edema: Immediate PositioningFirst action before the physician arrives
Acute dyspnea with frothy sputum after IV fluids suggests pulmonary edema. Place the patient sitting upright with legs dependent to reduce venous return and ease breathing.

Upright posture lowers the diaphragm and improves lung compliance. Dependent legs pool blood in the lower extremities, decreasing preload and pulmonary capillary pressure.

CautionDo not raise the legs or place the patient flat. These positions increase venous return and worsen pulmonary congestion. Slow the IV infusion and give oxygen as ordered while notifying the physician.

## 핵심 개념

- **Pulmonary edema** — Accumulation of fluid in the alveoli and interstitial space of the lungs, often from elevated pulmonary capillary hydrostatic pressure, causing dyspnea and frothy sputum.
- **Venous return** — The flow of blood back to the right atrium; reducing it decreases blood delivered to the pulmonary circulation and lowers pulmonary capillary pressure.
- **Dependent positioning** — Placing the legs below heart level so gravity pools blood in the lower extremities, reducing preload.
- **Frothy sputum** — Pink-tinged, air-mixed alveolar fluid that is a classic sign of acute pulmonary edema.

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