# Situation: During the hot season, the emergency department of a coastal district hospital receives three clients from a beach outing. Client 1 is a 24-year-old man who collapsed after a long run on the sand at midday. Client 2 is a 30-year-old woman who was pulled from the sea after being found face down in the water. Client 3 is a 35-year-old man who dove headfirst into shallow water and was pulled out by friends. Client 2 is alert and feels well, but she coughs frequently. One hour after arrival, her respiratory rate is 22/min, oxygen saturation is 95% on room air, and a few fine crackles are heard at the right lung base. She asks to go home. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630044  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: During the hot season, the emergency department of a coastal district hospital receives three clients from a beach outing. Client 1 is a 24-year-old man who collapsed after a long run on the sand at midday. Client 2 is a 30-year-old woman who was pulled from the sea after being found face down in the water. Client 3 is a 35-year-old man who dove headfirst into shallow water and was pulled out by friends.

Client 2 is alert and feels well, but she coughs frequently. One hour after arrival, her respiratory rate is 22/min, oxygen saturation is 95% on room air, and a few fine crackles are heard at the right lung base. She asks to go home. What should the nurse do?

## 보기

1. Keep her for observation, since lung injury can worsen over hours **✔ 정답**
2. Arrange a clinic check in 1 week to screen her for delayed drowning
3. Prepare her discharge, since her oxygen saturation is above 94%
4. Give a diuretic to remove the seawater absorbed into her lungs

**정답: 1**

## 해설

After a submersion event, only clients who are asymptomatic apart from a mild cough and have clear lungs may be released early. Frequent cough, tachypnea and crackles show aspiration, so she is kept for observation and reassessment because pulmonary injury can worsen over the following hours. Deterioration days later without earlier symptoms is not supported by evidence, so a delayed check does not replace observation now.

## 심화 해설

Clinical situation and immediate nursing judgment

Client 2 was submerged face down in seawater, is currently alert and asking to go home, but has a frequent cough, a respiratory rate of 22/min, oxygen saturation of 95% on room air, and fine crackles at the right lung base. These findings are not benign. The cough and focal crackles indicate that seawater has been aspirated into the lower airways, and the mildly elevated respiratory rate with borderline saturation suggests early impairment of gas exchange. Even when a near-drowning patient looks well initially, aspiration-related lung injury can progress over several hours, so discharge from the emergency department is not safe at this point.

Key point! The decision to observe is based on the combination of cough, tachypnea, and crackles. A truly low-risk patient would have no cough or only a very mild cough, a normal respiratory rate, normal oxygen saturation, and clear lungs on auscultation. Client 2 does not meet these criteria.

Why lung injury worsens after seawater aspiration

Seawater is hypertonic relative to plasma. When it enters the alveoli, it draws water from the pulmonary capillaries into the air spaces by osmosis, producing pulmonary edema and diluting or inactivating surfactant. The loss of surfactant leads to alveolar collapse and reduced lung compliance. In addition, seawater directly irritates the alveolar-capillary membrane, triggering an inflammatory response that increases capillary permeability [1][3]. This inflammatory phase develops over time, which explains why a patient can appear stable in the first hour and then deteriorate over the next several hours.

The clinical course of drowning-related lung injury is not always fully apparent on arrival; radiographic and gas-exchange abnormalities may take hours to become evident. In a retrospective cohort of adults hospitalized after seawater near-drowning, respiratory involvement was common and required ongoing monitoring because lung injury evolved during the early hospital course [1]. A mouse model of seawater drowning-induced acute lung injury similarly demonstrated that alveolar damage and inflammation progress after the initial aspiration event, supporting the need for early recognition and serial reassessment [3].

Interpreting the assessment findings

The respiratory rate of 22/min is at the upper limit of normal for an adult, but in the context of recent submersion it represents tachypnea and should be tracked over time. Oxygen saturation of 95% on room air is not reassuring in this setting because it may fall further as edema and inflammation progress. The fine crackles at the right lung base are the most specific finding; they indicate fluid in the small airways and alveoli, consistent with localized aspiration pneumonitis or early pulmonary edema.

| Finding | Interpretation in near-drowning | Nursing implication |
| --- | --- | --- |
| Frequent cough | Airway irritation from aspirated seawater; may persist as inflammation develops | Continue monitoring; do not dismiss as minor |
| Respiratory rate 22/min | Mild tachypnea; early sign of increased work of breathing | Reassess every 30–60 minutes |
| SpO2 95% on room air | Borderline; may decline as edema worsens | Monitor for downward trend; consider oxygen if below target |
| Fine crackles at right lung base | Fluid in alveoli or small airways from aspiration | Strong indication for continued observation |

Why the other options are incorrect

Watch out! Option 3 focuses only on the oxygen saturation value. A saturation above 94% is generally acceptable for a healthy person, but it does not override the presence of crackles, cough, and tachypnea after a submersion event. Discharging this client would risk missing progressive respiratory failure.

Option 4 is inappropriate because diuretics are not a first-line treatment for seawater aspiration. The fluid in the lungs after seawater drowning is not simply excess total body water that can be removed with a diuretic; it results from osmotic shifts and capillary leak driven by local inflammation [1][3]. Diuretics can cause systemic volume depletion without reliably clearing alveolar fluid and are not indicated in the initial management of drowning-related lung injury.

Option 2 suggests a clinic visit in one week to screen for delayed drowning. The concept of deterioration days later in a person who was initially asymptomatic is not well supported by evidence. When symptoms do develop, they typically appear within the first several hours after the event [1]. A delayed outpatient appointment cannot replace close observation during the early high-risk window.

Nursing priorities during observation

The nurse should keep Client 2 in the emergency department or observation unit, monitor respiratory rate, oxygen saturation, work of breathing, and lung sounds at regular intervals, and be prepared to obtain a chest radiograph or point-of-care ultrasound if oxygenation worsens or crackles spread. Point-of-care ultrasound can rapidly identify pulmonary edema when radiography is delayed or unavailable, as demonstrated in a non-fatal drowning case where diffuse B-lines indicated pulmonary edema . If oxygen saturation falls or respiratory distress increases, supplemental oxygen and early escalation of care are required. In severe cases that progress to acute respiratory failure, advanced supportive measures such as mechanical ventilation may become necessary .References (research sources)

- [1]Near-drowning: clinical course of lung injury in adults.Research articleGregorakos L, Markou N, Psalida V, Kanakaki M, Alexopoulou A, Sotiriou E (2009) · DOI: 10.1007/s00408-008-9132-4

- [3]Seawater drowning induced acute lung injury: new insights from novel mouse models and micro-CT imaging.Research articleLiu J, Li C, Yang Z, Wei Y, Liang Z, Ma X, Liu S, Ren J, Mo Z, Yin Y, Wang Z, Chen L. (2026) · DOI: 10.1515/med-2026-1510

## 임상 시나리오

Near-Drowning Observation CriteriaWhen to keep a submersion patient for monitoring
After a submersion event, only patients who are asymptomatic apart from a mild cough and have clear lungs on auscultation may be released early. Any sign of aspiration—such as frequent cough, tachypnea, or crackles—requires observation and reassessment.

Seawater is hypertonic and draws fluid into alveoli by osmosis, causing pulmonary edema and surfactant inactivation. Lung injury can worsen over hours, even if the patient initially appears well.

CautionDo not discharge based on a single normal SpO2 reading. Borderline saturation (95%) with tachypnea (22/min) and focal crackles indicates early gas exchange impairment. Diuretics are not indicated for seawater aspiration.

## 핵심 개념

- **aspiration lung injury** — Pulmonary damage caused by inhalation of fluid (e.g., seawater) into the lower airways, leading to inflammation, edema, and impaired gas exchange.
- **pulmonary edema** — Accumulation of fluid in the alveoli and interstitial spaces, impairing oxygen exchange; can result from hypertonic seawater drawing fluid into air spaces.
- **surfactant inactivation** — Loss of surfactant function due to dilution or chemical irritation, causing alveolar collapse and reduced lung compliance.
- **tachypnea** — Abnormally rapid breathing; a respiratory rate above normal, indicating respiratory distress or compensation.
- **crackles** — Fine, discontinuous lung sounds heard on auscultation, indicating fluid in alveoli or small airways.

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