# A nurse is caring for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) who was admitted 2 days ago for an exacerbation. The patient's oxygen saturation has decreased from 92% to 88% on 2L nasal cannula, respiratory rate has increased from 20 to 28 breaths per minute, and the patient appears increasingly restless and confused. Which assessment finding would be the most concerning early warning sign indicating potential rapid deterioration?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543597  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) who was admitted 2 days ago for an exacerbation. The patient's oxygen saturation has decreased from 92% to 88% on 2L nasal cannula, respiratory rate has increased from 20 to 28 breaths per minute, and the patient appears increasingly restless and confused. Which assessment finding would be the most concerning early warning sign indicating potential rapid deterioration?

## 보기

1. Blood pressure increase from 130/80 to 145/90 mmHg
2. New onset of cyanosis or use of accessory muscles **✔ 정답**
3. Temperature elevation from 98.6°F to 99.2°F (37°C to 37.3°C)
4. Heart rate increase from 88 to 96 beats per minute

**정답: 2**

## 해설

New onset cyanosis or accessory muscle use indicates severe respiratory distress and impending failure in COPD, requiring immediate intervention. Other options represent less critical changes manageable with monitoring.

## 심화 해설

Clinical Judgment
This question assesses the ability to identify early warning signs of clinical deterioration in a patient with COPD exacerbation. The key is to note the neurological changes that appear when physiological compensatory mechanisms begin to fail and Notify HCP! hypoxemia affects brain function. Option 2 presents new **confusion** and **restlessness** along with decreased oxygen saturation (88%), which are signs of early hypoxic encephalopathy, indicating the patient may progress to rapid respiratory failure. Other vital sign changes (blood pressure, pulse, low-grade fever) represent less urgent secondary compensatory responses in this context.

Memory Tip
**C**onfusion + **R**estlessness + **L**ow **S**pO2 = **C**ritical **R**espiratory **L**imitation (CRL). In COPD patients, "CRL" reminds you that immediate action is needed.

KR vs US
In Korea, there is a tendency to focus on more obvious symptoms like dyspnea and cyanosis, but the NGN/US approach emphasizes subtle neurological changes as the primary indicator of deterioration. "Anxiety" and "confusion" are interpreted not as mere discomfort, but as signals of a medical emergency requiring immediate assessment and intervention.

## 임상 시나리오

Clinical Practice Guide
When evaluating a patient with COPD exacerbation, follow the ABCDE approach. After Airway and Breathing, assess Disability (neurological status, GCS, confusion) before Circulation. If there is a change in mental status along with decreased SpO2, immediate physician notification is required for arterial blood gas analysis (ABGA) along with supplemental oxygen.
Caution
In SATA (Select All That Apply) questions, when asked to choose the "most concerning" finding, do not fall into the trap of listing all abnormal findings. You must select the most direct and clinically significant preceding indicator of deterioration. In this case, a low-grade fever or mild elevation in blood pressure/heart rate may be a result of infection or anxiety, but confusion is direct evidence of hypoxia.

## 핵심 개념

- **Hypoxemia (저산소혈증)** — A condition where the partial pressure of oxygen in arterial blood (PaO2) is abnormally low. It is a major complication during COPD exacerbation and can lead to brain dysfunction (confusion).
- **COPD Exacerbation (COPD 악화)** — Acute worsening of chronic obstructive pulmonary disease symptoms, characterized by difficulty breathing, increased coughing, and sputum production, often caused by infection and requiring hospitalization.
- **Early Warning Signs (조기 경고 징후)** — Subtle clinical changes that appear before a patient's condition rapidly deteriorates. In COPD, these include changes in mental status, increased respiratory rate, and decreased SpO2.
- **Respiratory Failure (호흡부전)** — A condition where the lungs fail to properly oxygenate the blood or remove carbon dioxide. It is a serious complication of COPD exacerbation.
- **Tachycardia (빈맥)** — A state in which the resting heart rate increases above the normal range (typically 100 beats per minute for adults). It is a common response to stress, pain, and hypoxia.

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