Clinical Judgement Case Study: The COPD Exacerbation
Case 1: Patient Profile: Mr. J, 68 years old. History of smoking (40 pack-years). Admitted for increased
shortness of breath.
Assessment Data (08:00):
O2 Sat: 88% on Room Air
RR: 24 breaths/min
Lungs: Wheezing heard in upper lobes
Position: Tripod positioning (leaning forward on table)
Q1: What is the Priority Intervention? A) Increase O2 to 6L via Nasal Cannula B) Administer Albuterol
Nebulizer C) Teach pursed-lip breathing D) Administer Morphine for anxiety
Correct Answer: C) Teach pursed-lip breathing (and start O2 low, e.g., 2L).
Nurse Head Explanation: Many students choose "High O2" (Option A). This is dangerous for COPD
patients because their drive to breathe is triggered by low oxygen levels. If you flood them with oxygen,
they may stop breathing (apnea).
Why C is best: Pursed-lip breathing creates back-pressure in the airways, keeping them open
longer and allowing trapped CO2 to escape. It is the safest, immediate non-drug intervention.
Case 2:
Q2: Evaluation (09:00) Patient is now lethargic. O2 Sat is 94%. PaCO2 is 65 mmHg (High).
Interpretation: The patient is retaining CO2 (Hypercapnia) and becoming narco-lethargic.
Action: Prepare for BiPAP or intubation. Stop high-flow oxygen if it was started.
Case 3: Heart Failure (Fluid Volume Overload)
Q3: Patient with CHF has gained 4 lbs in 24 hours and has crackles in lung bases. What is the priority
action?
A) Ask about diet history
B) Administer IV Furosemide (Lasix)
C) Elevate legs
Answer: B.
, Rationale: "Airway/Breathing/Circulation." Fluid in lungs (crackles) impairs gas exchange. You
need to pull the fluid off immediately. Diet history (A) is for later.
Case 4: Stroke (Dysphagia)
Q4: A patient recovering from a stroke begins coughing while drinking water. What do you do?
A) Encourage them to clear their throat
B) Switch to a straw
C) Keep NPO and request Speech Therapy consult
Answer: C.
Rationale: Coughing implies aspiration. Aspiration leads to pneumonia. You must stop all intake
until a professional swallow evaluation is done. Straws usually make aspiration worse by
delivering fluid too fast.
Case 5: Sepsis Alert
Q5: Post-op patient. BP 88/50, HR 110, Temp 102.5°F. What is the FIRST intervention?
A) Administer Tylenol
B) Start IV Fluids (Bolus)
C) Draw Blood Cultures
D) Start Antibiotics
Answer: B (or C depending on protocol, but usually Fluids first for BP). Standard Sepsis Bundle:
Fluids $\to$ Cultures $\to$ Antibiotics.
Rationale: Hypotension kills fastest. Fill the tank (fluids). You must draw cultures before
antibiotics, or the results will be skewed.
Case 6: DKA (Diabetic Ketoacidosis)
Q6: Patient arrives with fruity breath, confusion, and Glucose of 500. They are breathing rapidly
(Kussmaul). Which IV fluid do you start first?
A) D5W (Dextrose)
B) 0.9% Normal Saline
C) Insulin Drip
Answer: B.
Case 1: Patient Profile: Mr. J, 68 years old. History of smoking (40 pack-years). Admitted for increased
shortness of breath.
Assessment Data (08:00):
O2 Sat: 88% on Room Air
RR: 24 breaths/min
Lungs: Wheezing heard in upper lobes
Position: Tripod positioning (leaning forward on table)
Q1: What is the Priority Intervention? A) Increase O2 to 6L via Nasal Cannula B) Administer Albuterol
Nebulizer C) Teach pursed-lip breathing D) Administer Morphine for anxiety
Correct Answer: C) Teach pursed-lip breathing (and start O2 low, e.g., 2L).
Nurse Head Explanation: Many students choose "High O2" (Option A). This is dangerous for COPD
patients because their drive to breathe is triggered by low oxygen levels. If you flood them with oxygen,
they may stop breathing (apnea).
Why C is best: Pursed-lip breathing creates back-pressure in the airways, keeping them open
longer and allowing trapped CO2 to escape. It is the safest, immediate non-drug intervention.
Case 2:
Q2: Evaluation (09:00) Patient is now lethargic. O2 Sat is 94%. PaCO2 is 65 mmHg (High).
Interpretation: The patient is retaining CO2 (Hypercapnia) and becoming narco-lethargic.
Action: Prepare for BiPAP or intubation. Stop high-flow oxygen if it was started.
Case 3: Heart Failure (Fluid Volume Overload)
Q3: Patient with CHF has gained 4 lbs in 24 hours and has crackles in lung bases. What is the priority
action?
A) Ask about diet history
B) Administer IV Furosemide (Lasix)
C) Elevate legs
Answer: B.
, Rationale: "Airway/Breathing/Circulation." Fluid in lungs (crackles) impairs gas exchange. You
need to pull the fluid off immediately. Diet history (A) is for later.
Case 4: Stroke (Dysphagia)
Q4: A patient recovering from a stroke begins coughing while drinking water. What do you do?
A) Encourage them to clear their throat
B) Switch to a straw
C) Keep NPO and request Speech Therapy consult
Answer: C.
Rationale: Coughing implies aspiration. Aspiration leads to pneumonia. You must stop all intake
until a professional swallow evaluation is done. Straws usually make aspiration worse by
delivering fluid too fast.
Case 5: Sepsis Alert
Q5: Post-op patient. BP 88/50, HR 110, Temp 102.5°F. What is the FIRST intervention?
A) Administer Tylenol
B) Start IV Fluids (Bolus)
C) Draw Blood Cultures
D) Start Antibiotics
Answer: B (or C depending on protocol, but usually Fluids first for BP). Standard Sepsis Bundle:
Fluids $\to$ Cultures $\to$ Antibiotics.
Rationale: Hypotension kills fastest. Fill the tank (fluids). You must draw cultures before
antibiotics, or the results will be skewed.
Case 6: DKA (Diabetic Ketoacidosis)
Q6: Patient arrives with fruity breath, confusion, and Glucose of 500. They are breathing rapidly
(Kussmaul). Which IV fluid do you start first?
A) D5W (Dextrose)
B) 0.9% Normal Saline
C) Insulin Drip
Answer: B.
