# A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit with acute exacerbation. The patient presents with increased dyspnea, productive cough with purulent sputum, and confusion. Vital signs: BP 140/90 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air, temperature 101.2°F (38.4°C). ABG results show pH 7.32, PaCO2 58 mmHg, PaO2 55 mmHg, HCO3- 28 mEq/L. What is the nurse's priority action?

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> subject: Next Gen NCLEX

## 문제

A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit with acute exacerbation. The patient presents with increased dyspnea, productive cough with purulent sputum, and confusion. Vital signs: BP 140/90 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air, temperature 101.2°F (38.4°C). ABG results show pH 7.32, PaCO2 58 mmHg, PaO2 55 mmHg, HCO3- 28 mEq/L. What is the nurse's priority action?

## 보기

1. Administer prescribed bronchodilator nebulizer treatment immediately
2. Apply supplemental oxygen via nasal cannula at 2-3 L/min **✔ 정답**
3. Obtain sputum specimen for culture and sensitivity
4. Explain the patient's condition to the worried family members

**정답: 2**

## 해설

In COPD exacerbation with hypoxemia (O2 sat 88%) and respiratory acidosis, priority is low-flow oxygen (2-3 L/min) to correct hypoxemia while avoiding suppression of hypoxic drive. Other interventions (bronchodilators, sputum culture, family education) are important but secondary to oxygenation.

## 심화 해설

Understanding the Clinical Scenario

This patient is experiencing an acute exacerbation of COPD (AECOPD) with signs of acute respiratory failure. The ABG results reveal a pH of 7.32 (acidosis), PaCO₂ of 58 mmHg (elevated), and PaO₂ of 55 mmHg (hypoxemia). The HCO₃⁻ of 28 mEq/L indicates metabolic compensation for chronic CO₂ retention, but the low pH confirms an acute decompensation on top of a chronic condition. The patient's confusion is a critical neurological manifestation of severe hypoxemia and requires immediate intervention.

Priority Action Analysis

The NCLEX-RN exam uses the ABC (Airway, Breathing, Circulation) framework to establish priorities. In this case, the immediate threat to life is profound hypoxemia (PaO₂ 55 mmHg, O₂ sat 88%). While bronchodilators are essential for treating the underlying bronchoconstriction, their effect is not immediate. The physiological priority is to correct the oxygen deficit to prevent cardiac arrhythmia, further neurological deterioration, and respiratory arrest.

Applying supplemental oxygen via nasal cannula at 2-3 L/min is the correct initial action because it directly addresses the life-threatening hypoxemia. In COPD patients, the goal is to titrate oxygen to achieve an SpO₂ of 88-92% to avoid suppressing the hypoxic drive, but the immediate need to raise the dangerously low PaO₂ takes precedence. The evidence highlights that delays in recognizing and acting upon worsening symptoms in COPD are major drivers of hospitalization and mortality [1]. This patient's confusion signifies a delay in care-seeking has already occurred, making the nurse's rapid response critical. Differentiating this acute event from day-to-day symptom variation is a known challenge, but the presence of confusion and acute ABG changes confirms an exacerbation requiring urgent systemic intervention [2].

Why Other Options Are Not the Priority

Administering a bronchodilator (Option 1) addresses the ventilation component but does not immediately resolve the critical tissue hypoxia. Obtaining a sputum specimen (Option 3) is important for guiding antibiotic therapy but is a secondary intervention that does not address a life-threatening condition. Explaining the condition to the family (Option 4) is a psychosocial need that, while important, is deferred until physiological stability is achieved. The nurse's priority is to correct the hypoxemia, which is the direct cause of the patient's acute confusion and the most immediate threat to survival.References (research sources)

- [1]Determinants of delayed care-seeking during acute exacerbations of chronic obstructive pulmonary disease: protocol for a systematic review and meta-analysis.Meta-analysis/systematic reviewFang L, Zhu X, Li N, Gu Y. (2026) · DOI: 10.1136/bmjopen-2025-115416

- [2]Differentiating the start of an exacerbation from day-to-day variation in people with COPD: a systematic review.Meta-analysis/systematic reviewSyam S, Aboelhassan A, Althobiani MA, Uysal ÖF, Sulaiman N, Shah AJ, Mandal S, Mani AR, Porter JC, Hurst JR. (2026) · DOI: 10.1183/16000617.0212-2025

## 임상 시나리오

COPD Exacerbation with HypoxemiaImmediate Nursing Priority and Oxygen Titration
The ABC framework dictates that correcting life-threatening hypoxemia (PaO2 55 mmHg, SpO2 88%) is the priority. Apply supplemental oxygen immediately to prevent cardiac arrhythmia and neurological deterioration.

In COPD patients with chronic CO2 retention, titrate O2 to a target SpO2 of 88-92%. Start with a nasal cannula at 2-3 L/min and adjust based on ABG and clinical response to avoid suppressing the hypoxic drive.

CautionAltered mental status (confusion) in a COPD patient is a late and critical sign of severe hypoxemia. Do not delay oxygen administration to perform diagnostics like sputum culture or to administer slower-acting bronchodilators.

## 핵심 개념

- **Acute Respiratory Failure in COPD** — An acute decompensation marked by pH 45 mmHg, often triggered by infection, requiring immediate support of oxygenation and ventilation.
- **Hypoxic Drive Theory** — The concept that high supplemental O2 in chronic CO2 retainers may suppress respiratory drive; management aims for target SpO2 of 88-92% using controlled low-flow O2.
- **ABC Priority Framework** — A triage system where Airway and Breathing interventions take absolute precedence over Circulation, diagnostics, or psychosocial needs in acute care settings.

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