# Situation: A 30-year-old construction worker has a closed midshaft fracture of the right femur after a fall from scaffolding. He is placed in balanced skeletal traction with a pin through the distal femur while awaiting internal fixation. He has no other injuries and no significant medical history. Another nurse has called the rapid response team for his confusion, rapid breathing and oxygen saturation (SpO2) of 87%. Which action should the nurse take FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630433  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 30-year-old construction worker has a closed midshaft fracture of the right femur after a fall from scaffolding. He is placed in balanced skeletal traction with a pin through the distal femur while awaiting internal fixation. He has no other injuries and no significant medical history.

Another nurse has called the rapid response team for his confusion, rapid breathing and oxygen saturation (SpO2) of 87%. Which action should the nurse take FIRST?

## 보기

1. Raise the head of the bed and give oxygen **✔ 정답**
2. Draw a blood sample for arterial blood gases
3. Give prescribed paracetamol (acetaminophen) for the fever
4. Remove the traction weights so he can sit upright

**정답: 1**

## 해설

Low oxygen saturation with confusion and tachypnea is an airway-and-breathing emergency. While the team is on the way, the nurse raises the head of the bed and gives oxygen; blood gases, imaging and other orders follow.

## 심화 해설

An airway and breathing emergency
The client has confusion, rapid breathing, and an oxygen saturation of 87%, findings consistent with fat embolism syndrome. Whatever the cause, low oxygen saturation with confusion and tachypnea is a breathing emergency, and the first nursing action is to improve oxygenation. The rapid response team has already been called, so while it is on the way the nurse raises the head of the bed and gives oxygen. These two simple actions can be done immediately and directly address the life-threatening problem.

Why positioning and oxygen come first
Raising the head of the bed lets the diaphragm descend and improves lung expansion, and supplemental oxygen raises the oxygen delivered to the alveoli. The brain is very sensitive to hypoxemia, and his confusion already shows reduced cerebral oxygenation. Following the ABC priority (airway, breathing, circulation), any action that improves oxygenation takes precedence over diagnostic tests or treatment of less urgent problems. The head of the bed can be raised safely with skeletal traction in place.

Evaluating the other options
The other choices are reasonable at some point but are not first.

| Option | Value | Why not first |
| --- | --- | --- |
| Arterial blood gases | Confirms the degree of hypoxemia | A test; oxygen should not wait for the result |
| Paracetamol (acetaminophen) for fever | Comfort and reduced oxygen demand | Does not treat the hypoxemia |
| Remove traction weights | None at this point | Not done without an order; releasing traction displaces the fracture |
| Raise head of bed and give oxygen | Treats the immediate threat | Correct first action |

Watch out! Removing the traction weights so he can sit upright looks helpful but is wrong. Traction is not released without an order, and the bed can be raised without disturbing it.

After the first action
Once oxygen is running, the nurse monitors oxygen saturation, respiratory rate, and level of consciousness, prepares for blood gas sampling and imaging, and gives the rapid response team a concise report. If oxygenation does not improve, the team may need to support ventilation. Key point! When a client is hypoxemic, act on oxygenation first; diagnostics and other orders follow.

## 임상 시나리오

First Action for HypoxemiaFat embolism in traction
Confusion, rapid breathing, and SpO2 87% after a femur fracture signal a breathing emergency. The rapid response team is on the way.

The nurse raises the head of the bed and gives oxygen at once. Both improve oxygenation and can be done with the traction in place.

Blood gases, imaging, and fever treatment follow once oxygen is running; the nurse keeps monitoring saturation and mental status.

CautionDo not remove traction weights to sit the client up; traction is released only with an order.

## 핵심 개념

- **Rapid response team** — A team of critical care clinicians called to assess and treat a deteriorating client outside the ICU.
- **Oxygen saturation (SpO2)** — The percentage of hemoglobin carrying oxygen, measured noninvasively by pulse oximetry.
- **Arterial blood gases** — A blood test of arterial pH, oxygen, carbon dioxide, and bicarbonate used to assess gas exchange.
- **ABC priority** — The rule that airway, then breathing, then circulation are assessed and treated first.

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