# A 58-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The patient has been receiving nebulized bronchodilators and systemic corticosteroids for 3 days and shows signs of improvement. However, this morning the patient reports increased anxiety, tremors, and palpitations. Vital signs are: BP 150/90 mmHg, HR 110 bpm, RR 22/min, O2 sat 92% on 2L nasal cannula. What is the most appropriate nursing intervention?

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## 문제

A 58-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The patient has been receiving nebulized bronchodilators and systemic corticosteroids for 3 days and shows signs of improvement. However, this morning the patient reports increased anxiety, tremors, and palpitations. Vital signs are: BP 150/90 mmHg, HR 110 bpm, RR 22/min, O2 sat 92% on 2L nasal cannula. What is the most appropriate nursing intervention?

## 보기

1. Increase the oxygen flow rate to 4L/min via nasal cannula
2. Hold the next dose of furosemide and notify the healthcare provider **✔ 정답**
3. Encourage increased fluid intake to prevent dehydration
4. Administer the scheduled furosemide dose as ordered

**정답: 2**

## 해설

The patient's symptoms (anxiety, tremors, palpitations) are likely due to adverse effects of bronchodilators (e.g., beta-2 agonist overuse) or corticosteroids, not hypokalemia from furosemide. Furosemide is not standard for COPD exacerbation, and hypokalemia typically develops over hours to days. Holding furosemide and notifying the provider is appropriate to reassess the medication regimen.

## 심화 해설

Understanding the Clinical Picture

This patient is experiencing adverse effects related to their COPD exacerbation treatment. While nebulized bronchodilators and systemic corticosteroids are standard therapy, they carry significant side effect profiles. The reported symptoms of anxiety, tremors, and palpitations, combined with the vital signs showing tachycardia (HR 110 bpm) and hypertension (BP 150/90 mmHg), are classic manifestations of excessive beta-2 adrenergic stimulation from the bronchodilator therapy [2].

The question stem introduces a medication, furosemide, that is not part of the standard COPD exacerbation protocol described. The nursing intervention must prioritize safety by recognizing a potential medication error. Administering a drug that is not indicated and could worsen the patient's clinical status is a critical safety violation.

Analysis of the Correct Answer (Option 2)

Holding the furosemide and notifying the healthcare provider is the most appropriate action. The patient's presentation is consistent with a sympathomimetic response, not fluid overload. Furosemide, a loop diuretic, is not indicated here. Administering it could lead to dehydration and electrolyte imbalances, specifically hypokalemia. This is a crucial safety concern because hypokalemia can exacerbate cardiac irritability and increase the risk of serious dysrhythmias in a patient already experiencing tachycardia and palpitations [3]. As a nurse, questioning an order that seems clinically incongruent and potentially harmful is a core responsibility before proceeding.

Why the Other Options Are Incorrect

- Option 1: Increase the oxygen flow rate. The patient’s oxygen saturation is 92% on 2L nasal cannula. In a COPD patient, this is often within an acceptable target range to prevent suppressing the hypoxic drive while correcting hypoxemia. The symptoms of anxiety, tremors, and palpitations are not indicative of worsening hypoxemia but rather a medication side effect. Increasing oxygen is not the primary intervention for these symptoms and could lead to hypercapnia.

- Option 3: Encourage increased fluid intake. While hydration is generally good for patients with COPD to help mobilize secretions, it is not the priority intervention for acute sympathomimetic side effects. More critically, this action would be contraindicated if the nurse were to administer the furosemide, as it would counteract the drug's intended effect. The immediate concern is addressing the potential medication error and the patient's distressing symptoms.

- Option 4: Administer the scheduled furosemide dose as ordered. This is the most dangerous option. The patient has no clinical indication for a diuretic based on the information provided. The combination of a beta-agonist-driven tachycardia and potential diuretic-induced hypokalemia creates a high-risk scenario for life-threatening cardiac arrhythmias. The ECG changes associated with potassium disorders, such as the development of U-waves, flattened T-waves, and ST-segment depression in hypokalemia, are a serious concern that must be avoided [3]. The nurse must use clinical judgment to withhold the medication and seek clarification.References (research sources)

- [2]Anti-cholinergic bronchodilators versus beta2-sympathomimetic agents for acute exacerbations of chronic obstructive pulmonary disease.Research articleMcCrory DC, Brown CD. (2002) · DOI: 10.1002/14651858.cd003900

- [3]ECG frequency changes in potassium disorders: a narrative review.Research articleTeymouri N, Mesbah S, Navabian SMH, Shekouh D, Najafabadi MM, Norouzkhani N, Poudineh M, Qadirifard MS, Mehrtabar S, Deravi N. (2022)

## 임상 시나리오

Clinical Safety Guide: Furosemide in COPD ExacerbationPrioritizing medication review over symptom masking
The patient's tachycardia, tremors, and anxiety are classic signs of beta-2 agonist toxicity from bronchodilator therapy, not fluid overload. Always assess the clinical context before administering diuretics.

Administering furosemide without an indication for fluid overload can cause dehydration and critical electrolyte imbalances, specifically hypokalemia. This significantly increases the risk of cardiac dysrhythmias in a patient with a heart rate of 110 bpm.

CautionNever administer a medication that does not match the patient's clinical picture. Question any new or non-standard order that could cause harm, such as a diuretic in a patient with sympathomimetic symptoms, and promptly notify the healthcare provider.

## 핵심 개념

- **Beta-2 Agonist Toxicity** — Adverse effects from excessive stimulation of beta-2 adrenergic receptors, commonly presenting with tachycardia, tremors, anxiety, and palpitations.
- **Loop Diuretic (Furosemide)** — A medication that inhibits sodium and chloride reabsorption in the loop of Henle, used to treat fluid overload but can cause significant hypokalemia.
- **Medication Error Prevention** — A nursing priority involving the critical evaluation of prescribed medications for indications, contraindications, and potential adverse effects before administration.
- **Sympathomimetic Response** — Physiological effects that mimic the sympathetic nervous system, including increased heart rate, blood pressure, and anxiety, often triggered by medications like bronchodilators.
- **Hypokalemia** — A low serum potassium level that increases the risk of cardiac irritability and life-threatening dysrhythmias, especially in patients with tachycardia.

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