# A nurse is caring for a 55-year-old patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) who was admitted 2 hours ago. The patient is receiving oxygen at 2 L/min via nasal cannula and has an IV of normal saline infusing at 75 mL/hr. Which assessment finding should the nurse prioritize for immediate intervention in this patient?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543628  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 55-year-old patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) who was admitted 2 hours ago. The patient is receiving oxygen at 2 L/min via nasal cannula and has an IV of normal saline infusing at 75 mL/hr. Which assessment finding should the nurse prioritize for immediate intervention in this patient?

The patient presents with increased work of breathing, use of accessory muscles, and reports feeling "like I can't catch my breath." Vital signs show: temperature 99.2°F (37.3°C), heart rate 110 bpm, respiratory rate 28/min, blood pressure 150/90 mmHg, and oxygen saturation 85% on 2 L oxygen.

## 보기

1. Blood pressure of 150/90 mmHg
2. Oxygen saturation of 88% **✔ 정답**
3. Heart rate of 110 bpm
4. Temperature of 99.2°F (37.3°C)

**정답: 2**

## 해설

Oxygen saturation of 88% on supplemental oxygen indicates severe hypoxemia requiring immediate intervention to prevent respiratory failure in COPD exacerbation. Other vital sign abnormalities are less urgent in this context.

## 심화 해설

Understanding the Priority: Oxygenation in COPD Exacerbation

The patient's report of "I can't catch my breath," combined with the objective findings of increased work of breathing and accessory muscle use, signals a state of acute respiratory distress. In the initial assessment of such a patient, the nurse's immediate priority is to identify and address the most life-threatening physiological derangement. The guideline for the initial assessment of respiratory distress emphasizes a systematic approach where the evaluation of oxygenation and the detection of hypoxemia are paramount [1]. This is because hypoxemia directly threatens cellular function and can rapidly lead to cardiac dysrhythmias, neurological injury, and death if not corrected.

Analyzing the Assessment Findings

Let's examine each vital sign through the lens of immediate physiological threat:

*   Blood pressure of 150/90 mmHg: This reading indicates hypertension. In the context of acute respiratory distress, this is an expected compensatory response driven by sympathetic nervous system activation and anxiety. While it requires monitoring, it does not represent an immediate threat to tissue oxygenation.

*   Heart rate of 110 bpm: This finding is tachycardia. Similar to the elevated blood pressure, this is a compensatory mechanism to increase cardiac output and oxygen delivery in response to hypoxemia and increased work of breathing. The priority is to treat the underlying cause—the hypoxemia—which will likely lead to a resolution of the tachycardia.

*   Temperature of 99.2°F (37.3°C): This is a low-grade fever. While it could indicate an underlying infectious trigger for the COPD exacerbation, it is not an immediate, life-threatening concern that takes priority over a critical oxygen saturation level.

*   Oxygen saturation of 85%: This is a critically abnormal value. An SpO₂ of 85% corresponds to a partial pressure of arterial oxygen (PaO₂) of approximately 50-55 mmHg, indicating severe hypoxemia. This level is well below the minimum target saturation of 88-92% typically desired in acute COPD exacerbation to prevent both the consequences of hypoxia and the risk of hypercapnia from over-oxygenation. The initial assessment of respiratory distress requires immediate recognition of such severely deranged oxygenation as the trigger for urgent intervention [1].

Clinical Reasoning and the NCLEX-RN Priority-Setting Framework

The NCLEX-RN exam frequently tests the ability to prioritize care using frameworks like the ABCs (Airway, Breathing, Circulation). While all the provided options relate to "Circulation" or secondary assessments, the 85% oxygen saturation is a direct and critical indicator of a "Breathing" problem. The guideline underscores that the initial clinical examination must focus on evaluating the consequences of respiratory distress on vital functions, with pulse oximetry being a key tool for this immediate assessment [1]. The other vital sign abnormalities (hypertension, tachycardia, low-grade fever) are downstream compensatory or etiological factors. The immediate intervention must target the severe hypoxemia, which could involve increasing the oxygen flow rate, changing the delivery device, or preparing for non-invasive or invasive ventilation support. The finding of an SpO₂ of 85% on a patient already receiving supplemental oxygen is a clear signal that the current therapy is failing and immediate escalation is required to prevent respiratory arrest [1].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 COPDPrioritizing Oxygenation in Respiratory Distress
In a COPD exacerbation, an oxygen saturation of 85% indicates severe hypoxemia. This is the immediate priority because it directly threatens cellular function and can lead to cardiac dysrhythmias.

Findings like tachycardia (110 bpm) and hypertension (150/90 mmHg) are compensatory responses to the hypoxemia and increased work of breathing. Treat the underlying cause first.

CautionWhile administering oxygen, closely monitor for signs of CO2 retention in COPD patients. Titrate oxygen to a target saturation of 88-92% to avoid depressing the hypoxic respiratory drive.

## 핵심 개념

- **Hypoxemia** — Abnormally low level of oxygen in the blood, a direct threat to cellular function requiring immediate correction.
- **COPD Exacerbation** — An acute worsening of respiratory symptoms in a patient with chronic obstructive pulmonary disease, often triggered by infection.
- **Accessory Muscle Use** — Recruitment of neck, chest, and abdominal muscles to assist breathing, a key sign of severe respiratory distress.
- **Compensatory Mechanism** — Physiological responses like tachycardia and hypertension that the body uses to maintain oxygen delivery during stress.
- **Priority Setting** — The nursing process of identifying the most life-threatening patient problem to address first, often using the ABC (Airway, Breathing, Circulation) framework.

## 같은 주제 문제

- [A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted to the…](https://mymerci.kr/pages/nclex_q.php?qn_id=543619)
- [A 55-year-old patient with chronic heart failure is admitted to the medical unit with acut…](https://mymerci.kr/pages/nclex_q.php?qn_id=543620)
- [A nurse is caring for a 68-year-old patient with chronic heart failure who was admitted wi…](https://mymerci.kr/pages/nclex_q.php?qn_id=543621)
- [A nurse is caring for a 68-year-old patient with chronic heart failure who has been admitt…](https://mymerci.kr/pages/nclex_q.php?qn_id=543622)
- [A 72-year-old patient with a history of ischemic cardiomyopathy is admitted to the medical…](https://mymerci.kr/pages/nclex_q.php?qn_id=543623)
- [A 58-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted with a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543624)
- [A nurse is caring for a 68-year-old patient with acute exacerbation of chronic obstructive…](https://mymerci.kr/pages/nclex_q.php?qn_id=543625)
- [A 55-year-old patient with chronic heart failure is admitted to the medical unit with acut…](https://mymerci.kr/pages/nclex_q.php?qn_id=543626)

---

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

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