# 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?

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## 문제

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?

## 보기

1. Administer bronchodilators as prescribed
2. Encourage deep breathing and coughing exercises
3. Initiate supplemental oxygen therapy **✔ 정답**
4. Position the patient in Trendelenburg position

**정답: 3**

## 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.

## 심화 해설

Clinical Context & Priority Setting

In a patient with a known COPD exacerbation presenting with increasing dyspnea and an oxygen saturation of 85% on room air, the immediate physiological threat is severe hypoxemia. The nursing priority must align with the Airway, Breathing, Circulation (ABC) framework. While bronchodilators and breathing exercises are core components of COPD management, they address the underlying bronchoconstriction and ventilation pattern, which take time to effect change. The most time-sensitive need is to correct the critical oxygen deficit to prevent end-organ damage, making the initiation of supplemental oxygen the first and most urgent independent nursing action.

Pathophysiology & Rationale for Priority

The initial assessment of respiratory distress, as outlined in emergency medicine guidelines, emphasizes the immediate recognition and management of life-threatening hypoxemia [1]. In a COPD exacerbation, alveolar hypoventilation and ventilation-perfusion mismatch lead to a rapid decline in arterial oxygen content. An SpO₂ of 85% corresponds to a PaO₂ of approximately 50-55 mmHg, which is on the steep slope of the oxyhemoglobin dissociation curve. At this point, any further small decrease in ventilation can cause a precipitous drop in oxygen saturation and cardiac arrest. Initiating oxygen therapy directly and immediately increases the fraction of inspired oxygen, improving alveolar oxygen tension and rapidly stabilizing the patient's condition.

Analysis of Other Options

| Option | Why It Is Not the Priority |
| --- | --- |
| 1. Administer bronchodilators as prescribed | Bronchodilators reduce airway resistance and improve airflow but do not directly address the critical, immediate hypoxemia. Their onset of action, even when rapid, is slower than the direct provision of oxygen. Furthermore, the administration of a prescribed medication is a dependent nursing intervention that follows the initial stabilization of the ABCs. |
| 2. Encourage deep breathing and coughing exercises | These techniques are beneficial for secretion clearance and preventing atelectasis in a stable patient. However, a patient in acute, severe respiratory distress with an SpO₂ of 85% is often too dyspneic and fatigued to perform these exercises effectively. Forcing this intervention before correcting hypoxemia can increase oxygen consumption and worsen distress. |
| 4. Position the patient in Trendelenburg position | The Trendelenburg position (head lower than feet) is contraindicated in respiratory distress. It forces the abdominal contents against the diaphragm, restricting lung expansion and further compromising ventilation. The appropriate position is high-Fowler's or an upright tripod position to maximize chest wall expansion and diaphragmatic excursion. |

Evidence-Based Clinical Application

The formalized expert recommendations for the initial assessment of respiratory distress in the emergency setting provide a structured framework that is directly applicable to the bedside nurse [1]. The guideline's emphasis on a systematic initial assessment supports the ABC approach, where the "B" for breathing includes the immediate identification and correction of hypoxemia. For the NCLEX-RN examinee, this translates to recognizing that in any scenario where a patient has a patent airway but a critically low oxygen saturation, the application of oxygen is the first and most critical independent nursing intervention. Once the patient's oxygenation is stabilized, the nurse can then proceed with other collaborative interventions, such as administering prescribed bronchodilators and positioning the patient for optimal ventilation.

References (research sources)

- [1]Guidelines for the Initial Assessment of Respiratory Distress in the Emergency Department.GuidelineLe Borgne P, Thille AW, Guenezan J, Aissaoui N, Boureau AS, Bally C, Balen F, Basset A, Bilbault P, Boissier F, Claessens YE, Decavèle M, Diehl JL, Douillet D, Guillon A, Hausfater P, Javaudin F, Jezequel M, Kuteifan K, L'Her E, Marjanovic N, Maury E, Ohana M, Pichereau C, Ray P, Reuter PG, Tiberti N, Voiriot G, Yordanov Y, Le Conte P, Terzi N. (2026) · DOI: 10.1016/j.aicoj.2025.100005

## 임상 시나리오

Managing Acute Hypoxemia in COPD ExacerbationPrioritizing Oxygen Therapy Using the ABC Framework
For a COPD patient with increasing dyspnea and an SpO₂ of 85% on room air, the immediate priority is to initiate supplemental oxygen therapy. This directly corrects life-threatening hypoxemia to prevent end-organ damage, aligning with the 'Breathing' component of the ABC framework.

An SpO₂ of 85% correlates to a PaO₂ of 50-55 mmHg, placing the patient on the steep slope of the oxyhemoglobin dissociation curve where rapid decompensation can occur. Titrate oxygen to achieve a target saturation of 88-92% to avoid hypercapnia while stabilizing the patient.

CautionAvoid placing the patient in a Trendelenburg position, which is contraindicated as it increases pressure on the diaphragm and worsens respiratory distress. Bronchodilators and breathing exercises are secondary interventions following initial oxygenation.

## 핵심 개념

- **Hypoxemia** — Abnormally low concentration of oxygen in the arterial blood, indicated by an SpO₂ of 85% which correlates to a PaO₂ of approximately 50-55 mmHg.
- **COPD Exacerbation** — An acute worsening of respiratory symptoms in a patient with Chronic Obstructive Pulmonary Disease, often triggered by infection or environmental factors.
- **ABC Framework** — A systematic priority-setting approach in emergency care standing for Airway, Breathing, and Circulation, guiding immediate life-saving interventions.
- **Oxyhemoglobin Dissociation Curve** — A graph showing the relationship between oxygen saturation and partial pressure of oxygen; at the steep slope (SpO₂ < 90%), small pressure drops cause large saturation declines.

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