# A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who reports severe dyspnea and anxiety. The patient received albuterol via nebulizer 30 minutes ago with minimal relief. Which nursing intervention should the nurse implement first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542644  
> language: ko  
> subject: Fundamentals

## 문제

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who reports severe dyspnea and anxiety. The patient received albuterol via nebulizer 30 minutes ago with minimal relief. Which nursing intervention should the nurse implement first?

## 보기

1. Assess the patient's respiratory status and oxygen saturation **✔ 정답**
2. Administer supplemental oxygen as prescribed
3. Position the patient in high Fowler's position to ease breathing
4. Teach pursed-lip breathing techniques to reduce dyspnea

**정답: 1**

## 해설

Assessing respiratory status and oxygen saturation is the priority to evaluate the effectiveness of albuterol and guide further interventions for dyspnea and anxiety. Other options may be appropriate after assessment.

## 심화 해설

Clinical Reasoning and Prioritization

In a patient with COPD presenting with severe dyspnea and anxiety, the immediate priority is a focused assessment to determine the cause of the minimal response to initial bronchodilator therapy. While the patient's report of symptoms is critical, the nurse must first obtain objective data to guide all subsequent interventions safely and effectively. The nursing process mandates assessment as the initial step, especially when a patient's condition is not improving as expected.

Albuterol, a short-acting beta-agonist, works by relaxing bronchial smooth muscle to relieve bronchospasm. When relief is minimal, it signals a potential worsening of the underlying pathophysiology, such as a severe exacerbation, mucus plugging, or the development of a complication like pneumonia or pneumothorax. A COPD exacerbation is defined by a sustained worsening of respiratory symptoms beyond normal day-to-day variations [1]. Jumping to other interventions without a rapid, systematic assessment could delay the recognition of a life-threatening decline in gas exchange.

Assessment must precede intervention. The guideline for initial assessment of respiratory distress emphasizes a structured clinical evaluation to determine severity and etiology before initiating or escalating therapies . The nurse's first action should be to evaluate the patient's current respiratory status, including work of breathing, breath sounds, and level of consciousness, alongside a measurement of oxygen saturation (SpO2). This data is essential to determine if the patient is experiencing hypoxemia and to what degree. In COPD, a target SpO2 range of 88-92% is recommended to avoid the risks of hyperoxia, such as worsening hypercapnia, while ensuring adequate tissue oxygenation [1].

The other options represent important interventions, but they are not the first step. Administering supplemental oxygen (Option 2) is a high-priority intervention, but it must be titrated based on a current SpO2 reading to meet the specific target range [1]. Positioning the patient in high Fowler's position (Option 3) is a low-risk, comfort-focused intervention that can be done concurrently with or immediately after the initial assessment. Teaching pursed-lip breathing (Option 4) is a valuable strategy for managing dyspnea and is a component of pulmonary rehabilitation, which is a cornerstone of non-pharmacological COPD management . However, it is an intervention for a stable patient and is not the priority during an acute episode of severe distress where the patient may not be able to follow instructions effectively. Psychological support is also important for COPD patients who often experience anxiety, but the immediate physiological threat must be addressed first .

References (research sources)

- [1]Respiratory Care Management of COPD Exacerbations.Research articleHess DR. (2023) · DOI: 10.4187/respcare.11069

## 임상 시나리오

Clinical Practice Guide: Prioritizing Assessment in Acute COPD Dyspnea

When a COPD patient reports severe dyspnea with minimal relief after initial bronchodilator therapy, the nurse must first perform a rapid, focused cardiopulmonary assessment. This includes evaluating work of breathing, accessory muscle use, breath sounds, level of consciousness, and obtaining a pulse oximetry reading. This objective data is essential to differentiate between a severe exacerbation, mucus plugging, pneumothorax, or other complications before escalating interventions.

Administering supplemental oxygen without a current SpO2 and a valid prescription risks inducing hypercapnia in CO2 retainers. High Fowler's position and breathing techniques are supportive measures that follow the initial assessment. The nursing process dictates that assessment always precedes implementation, especially when a patient's condition is deteriorating unexpectedly.

Key actions during the focused assessment include auscultating for diminished or absent breath sounds, checking for paradoxical chest movement, and monitoring for signs of impending respiratory failure such as altered mental status or bradypnea. Prepare for potential escalation, including non-invasive ventilation or transfer to a higher level of care, based on assessment findings.

## 핵심 개념

- **Albuterol** — A short-acting beta-agonist bronchodilator that relaxes bronchial smooth muscle to relieve acute bronchospasm.
- **COPD Exacerbation** — A sustained worsening of respiratory symptoms beyond normal day-to-day variations, often triggered by infection or environmental factors.
- **Nursing Process** — A systematic framework (Assessment, Diagnosis, Planning, Implementation, Evaluation) requiring assessment as the foundational first step.
- **Pulse Oximetry (SpO2)** — A non-invasive method to estimate arterial oxygen saturation, crucial for guiding oxygen therapy in respiratory distress.

## 같은 주제 문제

- [A nurse is assessing a 68-year-old postoperative patient who underwent abdominal surgery 2…](https://mymerci.kr/pages/nclex_q.php?qn_id=542638)
- [A nurse is assessing a 45-year-old patient with chronic osteoarthritis who reports persist…](https://mymerci.kr/pages/nclex_q.php?qn_id=542639)
- [A nurse is assessing a 35-year-old patient with chronic low back pain who has been taking …](https://mymerci.kr/pages/nclex_q.php?qn_id=542640)
- [A nurse is assessing a 45-year-old patient with chronic lower back pain who has been takin…](https://mymerci.kr/pages/nclex_q.php?qn_id=542641)
- [A nurse is caring for a postoperative patient who reports severe incisional pain rated 8/1…](https://mymerci.kr/pages/nclex_q.php?qn_id=542642)
- [A nurse is caring for a patient with chronic pain who has been receiving morphine 10 mg IV…](https://mymerci.kr/pages/nclex_q.php?qn_id=542643)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._