A nurse is caring for a 58-year-old patient diagnosed with COPD exacerbation who is experiencing increasing dyspnea and oxygen saturation of 85% on room air. Which nursing intervention should be the priority?
1Administer bronchodilators as prescribed
2Encourage deep breathing and coughing exercises
3Initiate supplemental oxygen therapy✓ 정답
4Position the patient in Trendelenburg position
해설
Supplemental oxygen is the priority to correct hypoxia (SpO2 85%) and prevent tissue damage, as it addresses the immediate ABC (airway, breathing, circulation) need. Other options are less urgent or contraindicated in this context.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize interventions for a patient with Chronic Obstructive Pulmonary Disease (COPD) experiencing an exacerbation. The core theme is Airway, Breathing, Circulation (ABC) prioritization. The patient's key data are severe dyspnea and an oxygen saturation (SpO2) of 85% on room air, indicating significant hypoxemia. In COPD, chronic hypercapnia (elevated CO2) can blunt the drive to breathe, making some patients "hypoxic drivers." However, during an acute exacerbation with severe hypoxemia, correcting life-threatening low oxygen levels is the immediate priority to prevent organ damage.
Answer Rationale: Key Point! The priority nursing intervention is to Initiate supplemental oxygen therapy. An SpO2 of 85% represents a critical threat to the patient's Airway, Breathing, Circulation (ABC) status. The primary goal is to rapidly correct hypoxemia to prevent tissue hypoxia, cardiac arrhythmias, and further respiratory distress. While oxygen must be administered cautiously in COPD patients (often starting with low flow rates like 2 L/min via nasal cannula), severe hypoxemia itself is an immediate threat to life and must be addressed first. This intervention directly supports the "B" (Breathing) in the ABC framework.
Distractor Analysis:
Watch out for confusion! Option ①, "Administer bronchodilators as prescribed," is an important intervention for COPD exacerbation to relieve bronchospasm, but it is not the immediate priority when the patient's oxygen level is critically low. Medication administration takes time to act, while oxygen works immediately to support vital functions.
Option ②, "Encourage deep breathing and coughing exercises," is a valuable therapeutic measure to improve ventilation and clear secretions, but it is inappropriate and potentially harmful to ask a severely hypoxemic, dyspneic patient to perform these exercises before stabilizing their oxygenation. This is a supportive, not a priority, intervention.
Option ④, "Position the patient in Trendelenburg position," is contraindicated for a patient with respiratory distress. The Trendelenburg position (head down, feet up) increases pressure on the diaphragm from abdominal contents, further compromising lung expansion and worsening dyspnea. The correct position for a dyspneic patient is High-Fowler's position (sitting upright) to maximize chest expansion.
Related Concepts: Managing a COPD patient requires balancing the correction of hypoxemia with the risk of suppressing the hypoxic drive. The nurse must monitor for signs of oxygen-induced hypoventilation (increased somnolence, decreased respiratory rate, rising PaCO2). However, the initial action for severe hypoxemia is always to administer oxygen and then closely monitor the patient's response.
Concept Summary
Concept
Explanation
ABC Prioritization
Airway, Breathing, Circulation. The foundational framework for establishing care priorities. Life-threatening breathing issues (severe hypoxemia) take precedence.
Hypoxic Drive
A backup respiratory stimulus in some severe COPD patients where low O2 (not high CO2) is the main trigger to breathe. Overly aggressive O2 can suppress this.
COPD Exacerbation
An acute worsening of respiratory symptoms (dyspnea, cough, sputum) requiring a change in medication. Often triggered by infection.
Oxygen Therapy in COPD
Goal is to achieve SpO2 of 88-92% (per guidelines). Start low (e.g., 2 L/min NC), titrate up based on SpO2 and ABGs, avoiding >95% saturation.
Side-by-Side Comparison!
Intervention
Priority in Severe Hypoxemia (SpO2 85%)
Rationale
Supplemental Oxygen
FIRST (Immediate)
Directly corrects the life-threatening deficit in oxygenation (ABCs - Breathing).
Bronchodilator Administration
SECOND (Urgent, after O2 initiated)
Addresses the cause of obstruction but takes minutes to work. Oxygen is needed now.
Positioning (High-Fowler's)
CONCURRENT (Can be done with O2)
Supports breathing mechanics but does not directly increase FiO2 like oxygen therapy does.
Breathing Exercises
LATER (After stabilization)
Therapeutic but requires patient effort and cooperation, which is impossible during severe distress.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: In COPD, chronic inflammation leads to narrowed airways (chronic bronchitis) and/or destroyed alveoli (emphysema). This causes air trapping, increased work of breathing, and impaired gas exchange (low O2, high CO2).
Gas Exchange: Normal PaO2 is 80-100 mmHg and SpO2 is 95-100%. An SpO2 of 85% corresponds to a dangerously low PaO2.
Pharmacology: First-line drugs for COPD exacerbation are short-acting beta-agonists (SABAs) like albuterol and anticholinergics like ipratropium, often given via nebulizer.
Memory Tips
ABCs Rule: Always ask: "Is the Airway open? Is the patient Breathing? Is there Circulation?" For this patient, Breathing (O2 saturation) is the clear problem.
O2 Saturation Mnemonic: "88-92, Keep Them Alive" – The target SpO2 range for most COPD patients to avoid both hypoxemia and suppressing the hypoxic drive.
Positioning: Think "High and Dry" for breathing problems – High-Fowler's position.
High-Frequency NCLEX Topics
This scenario tests prioritization (ABCs) and application of knowledge for a chronic illness exacerbation, both core NCLEX concepts. Expect questions on: 1) Recognizing abnormal vital signs (low SpO2), 2) Choosing the immediate vs. important intervention, 3) Knowing contraindicated actions (Trendelenburg position for respiratory issues), and 4) Understanding disease-specific management (cautious O2 in COPD).
Watch Out for Question Variations!
Shift in Data: If the SpO2 was 92% and the patient was anxious, the priority might shift to administering a bronchodilator or positioning.
Shift in Focus: "Which assessment is priority after initiating oxygen?" Answer: Monitor respiratory rate and level of consciousness for signs of hypoventilation.
Pharmacology Focus: "The patient receives albuterol via nebulizer. Which patient statement indicates effective teaching?" Answer: "I should rinse my mouth after using this to prevent thrush."
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit. Mr. Johnson, 58, with a history of COPD, was admitted yesterday for increased shortness of breath and cough. This morning, he appears more distressed, using accessory muscles to breathe. His SpO2 on room air is 85%, respiratory rate is 28, and he speaks in short phrases.
Nursing Intervention Strategy:
Immediate Action (Priority): Apply nasal cannula and initiate oxygen at 2 liters per minute. Re-check SpO2 in 1-2 minutes. Inform the provider of the patient's status and your action.
Concurrent Actions: Assist the patient into High-Fowler's position. Stay with the patient to provide reassurance and decrease anxiety, which can worsen dyspnea.
Assessment: Perform a focused respiratory assessment: breath sounds (listen for wheezes, diminished sounds), work of breathing, and mental status. A change in LOC is an early sign of rising CO2.
Subsequent Interventions: Administer prescribed nebulized bronchodilators (e.g., albuterol/ipratropium). Encourage fluid intake if not contraindicated to help thin secretions. Plan for coughing/deep breathing exercises after the acute distress subsides.
Evaluation: The primary goal is to improve oxygenation (target SpO2 88-92%) and reduce work of breathing. Evaluate the effectiveness of oxygen therapy and medications.
Patient Safety and Precautions:
Oxygen Caution: Use the lowest flow rate necessary to achieve target saturation. Avoid high concentrations that could lead to CO2 narcosis in susceptible patients.
Medication: Monitor for tachycardia and tremors (side effects of beta-agonists like albuterol).
Positioning: Never use Trendelenburg for respiratory distress. Ensure the patient's arms are supported on pillows or an over-bed table to optimize chest expansion.
Nursing Procedure & Medication FlowOxygen Therapy Initiation for COPD:
1. Verify provider's order for oxygen (in an emergency, protocol may allow initiation with subsequent order).
2. Select delivery device: Nasal cannula for low flow (1-6 L/min, FiO2 24-44%).
3. Set flowmeter to prescribed rate (often start at 2 L/min for COPD).
4. Apply cannula, ensuring prongs are directed downward into nares.
5. Re-assess SpO2 within 5 minutes and titrate flow up or down to maintain SpO2 88-92%.
6. Document: Device, flow rate, patient's SpO2 before and after, and tolerance.
A Word from Your Senior Nurse
"In the rush of an exacerbation, it's easy to get caught up in tasks. Remember your ABCs – they are your North Star for prioritization. For Mr. Johnson, that low SpO2 is a red flag you cannot ignore. Giving oxygen isn't just a task; it's buying time for his body and for the medications to work. Always pair your intervention with your assessment. After you turn on the O2, don't just walk away. Watch his chest rise, listen to his breath sounds, and look into his eyes. Is he less panicked? Is his color improving? That's how you know your nursing care is making a difference. Connect the dots between the pathophysiology (his damaged lungs can't get enough O2) and your action (giving him O2). That's the thinking the NCLEX tests and that real nursing requires."
Chronic Obstructive Pulmonary Disease — A progressive lung disease characterized by persistent airflow limitation, usually caused by chronic bronchitis and/or emphysema.
Hypoxemia — A low level of oxygen in the blood, typically defined as an arterial oxygen tension (PaO2) less than 80 mmHg or SpO2 less than 95%.
ABC Prioritization — A systematic approach to patient assessment and intervention focusing first on Airway, then Breathing, then Circulation.
High-Fowler's Position — A sitting position where the head of the bed is raised to 80-90 degrees. Used to maximize lung expansion in patients with respiratory difficulty.
Hypoxic Drive — A secondary stimulus for breathing in some severe COPD patients where low blood oxygen, rather than high carbon dioxide, is the primary respiratory trigger.