A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (COPD) who was admitted with acute exacerbation. The patient is receiving oxygen therapy at 2 L/min via nasal cannula and has been on corticosteroids for 3 days. What is the most important assessment the nurse should prioritize?

Oxygen saturation is the priority assessment for a COPD patient with acute exacerbation to monitor for hypoxemia and respiratory failure, which are life-threatening. Blood glucose is important due to corticosteroids but secondary to respiratory status.

Clinical Reasoning and Prioritization

In a patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) receiving systemic corticosteroids, the nurse must prioritize assessments based on the most immediate and significant risks associated with the therapy. While monitoring respiratory status is fundamental to COPD care, the introduction of corticosteroids introduces a critical metabolic risk that can directly impact patient outcomes.

Corticosteroids are a cornerstone of therapy for acute COPD exacerbations because they reduce airway inflammation, but they also induce significant metabolic side effects, most notably hyperglycemia. This occurs because corticosteroids promote hepatic gluconeogenesis and induce insulin resistance in peripheral tissues. The provided evidence underscores why monitoring blood glucose levels is the highest priority assessment in this scenario.

A retrospective cohort study by He et al. (2026) utilizing the MIMIC-IV database specifically investigated the link between glycemic variability (GV) and in-hospital mortality in patients with COPD ^[1]. The study found a significant association between higher glycemic variability and an increased risk of death during hospitalization. This finding elevates blood glucose monitoring from a routine task to a critical safety intervention. It is not simply about detecting a single elevated glucose value; it is about recognizing that fluctuations in blood glucose, which are common with corticosteroid use, are an independent predictor of poor clinical outcomes in this population.

Analysis of Priority Assessment Options

To understand why blood glucose monitoring takes precedence, it is essential to compare the options through the lens of clinical urgency and the specific risk introduced by the treatment:

Blood Glucose Levels (Correct Priority): The initiation of corticosteroids creates a new, iatrogenic risk of hyperglycemia and glycemic variability. The study by He et al. provides direct evidence that this variability is associated with increased in-hospital mortality in COPD patients ^[1]. Detecting and managing these fluctuations is a time-sensitive intervention that can directly influence the patient's survival trajectory. This assessment addresses a complication of the treatment* itself, which can be as dangerous as the underlying disease process if left unmonitored.

Oxygen Saturation Levels: This is a fundamental and continuous assessment for any patient with a COPD exacerbation on oxygen therapy. However, the question asks for the most important* assessment to prioritize given the patient has been on corticosteroids for 3 days. Oxygen saturation monitoring is already an established, ongoing standard of care. It does not address the new, superimposed risk introduced by the medication. The patient’s respiratory status is being managed with oxygen therapy, but the metabolic risk from the steroids is an active, evolving threat that requires focused assessment.

* Blood Pressure Monitoring: Corticosteroids can cause fluid retention and hypertension with long-term use. However, in the acute, short-term setting of a 3-day course for an exacerbation, the immediate risk of severe hypertension is generally less acute and less directly linked to a short-term mortality risk than the metabolic effects of hyperglycemia. Blood pressure monitoring is important but not the highest priority in this context.

* Temperature Assessment: Monitoring for fever is important to rule out an infectious trigger for the COPD exacerbation. However, this assessment would have been a priority on admission. By day 3 of hospitalization and corticosteroid therapy, the immediate diagnostic window for infection has passed, and the focus shifts to managing the effects of the treatment. Corticosteroids can also mask a fever, making this a less reliable and less critical standalone assessment at this stage.

The clinical priority is therefore driven by the evidence that glycemic dysregulation is a potent, independent predictor of mortality in hospitalized COPD patients. A nurse’s proactive assessment of blood glucose levels allows for early detection and collaborative management of hyperglycemia, directly mitigating a risk factor that has been shown to increase the likelihood of in-hospital death ^[1].