# Situation: A 66-year-old man with chronic obstructive pulmonary disease (COPD) is admitted to the medical ward with increasing breathlessness and purulent sputum for 3 days. He has smoked for 40 years. His clinic record contains an arterial blood gas (ABG) result taken 3 months ago when he was stable, and the physician orders a repeat ABG on admission. On the second night, he asks for his as-needed oral diazepam because he cannot sleep. He is drowsy, complains of a new headache, and his respiratory rate is 12/min; his oxygen saturation (SpO2) is 90% on oxygen by Venturi mask at 28%. Which action is BEST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629708  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 66-year-old man with chronic obstructive pulmonary disease (COPD) is admitted to the medical ward with increasing breathlessness and purulent sputum for 3 days. He has smoked for 40 years. His clinic record contains an arterial blood gas (ABG) result taken 3 months ago when he was stable, and the physician orders a repeat ABG on admission.

On the second night, he asks for his as-needed oral diazepam because he cannot sleep. He is drowsy, complains of a new headache, and his respiratory rate is 12/min; his oxygen saturation (SpO2) is 90% on oxygen by Venturi mask at 28%. Which action is BEST?

## 보기

1. Give the drug and recheck his respiratory rate in 30 minutes
2. Give half of the prescribed dose and recheck him in 1 hour
3. Give the drug and keep him in a high Fowler's position
4. Withhold the drug and report the drowsiness and headache **✔ 정답**

**정답: 4**

## 해설

In a client with COPD, new drowsiness and headache are early signs of rising carbon dioxide (carbon dioxide narcosis) from hypoventilation. A benzodiazepine depresses breathing further and can precipitate respiratory failure, so the nurse holds it and reports the change so the physician can reassess, often with a repeat ABG. Delaying the report to recheck later risks respiratory failure after the sedative.

## 심화 해설

Why the answer is 4: Withhold the drug and report the drowsiness and headache

In a patient with advanced COPD, the combination of new-onset drowsiness, headache, and a reduced respiratory rate of 12/min while already receiving supplemental oxygen is a clinical red flag. These findings suggest carbon dioxide narcosis—a state in which rising arterial CO₂ from hypoventilation depresses the central nervous system. The patient’s baseline ABG from 3 months ago reflects his stable compensated state, but the current presentation indicates acute deterioration on top of chronic retention.

Benzodiazepines such as diazepam act as central nervous system depressants that blunt the ventilatory drive, particularly the hypoxic and hypercapnic responses that a COPD patient relies on to maintain breathing. In a patient already showing signs of CO₂ retention, administering diazepam—even at half the prescribed dose—can further suppress respiratory effort and precipitate acute hypercapnic respiratory failure. The risk is not merely theoretical; it is a direct pharmacodynamic interaction between the sedative and an already compromised respiratory control system.

The patient’s as-needed diazepam order was written for insomnia, but the current clinical picture is not simple sleeplessness. Watch out! New headache and drowsiness in a COPD patient on oxygen are not benign symptoms of anxiety or fatigue—they are early neurologic manifestations of hypercapnia. Treating them with a sedative would mask the underlying deterioration while simultaneously worsening its cause.

The safest nursing action is to hold the benzodiazepine and promptly communicate the change in mental status, headache, and respiratory pattern to the physician, who can reassess with a repeat ABG and adjust ventilatory support or oxygen therapy. Delaying the report to recheck the patient in 30 minutes or 1 hour after giving the drug creates a dangerous window during which respiratory failure could progress unnoticed.

| Option | Why it is incorrect |
| --- | --- |
| 1. Give the drug and recheck in 30 minutes | Administers a respiratory depressant to a patient already showing signs of hypoventilation; rechecking later does not prevent the initial harm. |
| 2. Give half the dose and recheck in 1 hour | Dose reduction does not eliminate the risk of further respiratory depression in a vulnerable COPD patient; the delay in reassessment compounds the danger. |
| 3. Give the drug and keep in high Fowler’s position | Positioning may aid lung expansion, but it cannot counteract the central respiratory depressant effect of diazepam in a patient with suspected CO₂ narcosis. |
| 4. Withhold the drug and report the drowsiness and headache | Correct. Prevents additional ventilatory suppression and triggers timely medical reassessment, including possible repeat ABG. |

The role of the nurse in this scenario is to recognize that the patient’s request for sleep medication is secondary to a more urgent physiologic problem. Key point! In COPD, a falling respiratory rate with drowsiness and headache indicates that the patient is retaining CO₂; any sedative-hypnotic must be withheld until the cause is clarified and the patient’s ventilatory status is stabilized. The physician’s order for a repeat ABG on admission supports the expectation that objective gas exchange data will guide further decisions, but the immediate nursing priority is to avoid adding a respiratory depressant and to escalate the concerning findings without delay.

## 임상 시나리오

COPD Deterioration and Sedative SafetyRecognizing CO2 Narcosis Before Giving Benzodiazepines
New drowsiness and headache in a COPD patient with a respiratory rate of 12/min on oxygen suggest carbon dioxide narcosis. These are early neurologic signs of rising PaCO2 from hypoventilation, not simple insomnia.

Benzodiazepines like diazepam depress the central nervous system and blunt both hypoxic drive and hypercapnic drive. In a patient already retaining CO2, even a reduced dose can precipitate acute hypercapnic respiratory failure.

CautionWithhold the sedative and report immediately. Do not delay for rechecks or repositioning; the priority is physician reassessment, often with a repeat arterial blood gas.

## 핵심 개념

- **Carbon dioxide narcosis** — A state of central nervous system depression caused by markedly elevated arterial CO2 levels from hypoventilation, presenting with drowsiness, headache, and reduced respiratory rate.
- **Hypoxic drive** — A respiratory stimulus dependent on low oxygen levels rather than CO2; COPD patients with chronic CO2 retention may rely on this drive, which sedatives can suppress.
- **Benzodiazepine** — A central nervous system depressant drug class that can blunt ventilatory responses and worsen hypercapnia in patients with compromised respiratory function.
- **Venturi mask** — A high-flow oxygen delivery device that provides a precise, fixed fraction of inspired oxygen, used cautiously in COPD to avoid suppressing hypoxic drive.
- **Arterial blood gas** — A blood test measuring pH, PaCO2, PaO2, and bicarbonate to assess acid-base balance and gas exchange, essential for monitoring COPD decompensation.

## 같은 주제 문제

- [Situation: A 46-year-old man is admitted to the medical ward after 3 days of profuse water…](https://mymerci.kr/pages/nclex_q.php?qn_id=629696)
- [Situation: A 46-year-old man is admitted to the medical ward after 3 days of profuse water…](https://mymerci.kr/pages/nclex_q.php?qn_id=629697)
- [Situation: A 46-year-old man is admitted to the medical ward after 3 days of profuse water…](https://mymerci.kr/pages/nclex_q.php?qn_id=629698)
- [Situation: A 64-year-old man with chronic atrial fibrillation and hypertension takes digox…](https://mymerci.kr/pages/nclex_q.php?qn_id=629699)
- [Situation: A 64-year-old man with chronic atrial fibrillation and hypertension takes digox…](https://mymerci.kr/pages/nclex_q.php?qn_id=629700)
- [Situation: A 64-year-old man with chronic atrial fibrillation and hypertension takes digox…](https://mymerci.kr/pages/nclex_q.php?qn_id=629701)
- [Situation: A 64-year-old man with chronic atrial fibrillation and hypertension takes digox…](https://mymerci.kr/pages/nclex_q.php?qn_id=629702)
- [Situation: A 49-year-old woman who had most of her small bowel removed 6 months ago is adm…](https://mymerci.kr/pages/nclex_q.php?qn_id=629703)

---

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

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