Clinical Judgment Case Study • 2026 Test Plan
64-year-old male • Emergency Department
A 64-year-old male with a 40-pack-year smoking history and known chronic obstructive pulmonary disease (COPD) is brought to the emergency department by ambulance for increased shortness of breath and productive cough for 3 days. Past medical history: COPD (GOLD stage III), coronary artery disease with stent placement 3 years ago, and hypertension. Home medications: tiotropium inhaler once daily, salbutamol (albuterol) inhaler PRN, atorvastatin 20 mg nightly, lisinopril 10 mg daily. He uses home oxygen at 2 L/min at night. Family reports he has been more lethargic and has had poor oral intake. Vital signs on arrival: BP 142/84 mmHg, HR 110 bpm, RR 26 breaths/min, SpO₂ 88% on room air, T 37.4°C (99.3°F). Lung exam: diffuse expiratory wheezes and decreased breath sounds bilaterally with scattered coarse crackles at bases. The client is anxious, speaking in short phrases, and able to follow commands.
The client’s work of breathing increases. He is more somnolent and difficult to arouse between verbal stimuli. Vital signs: RR 30 breaths/min, SpO₂ 85% on 4 L nasal cannula, HR 118 bpm, BP 130/78 mmHg, T 38.0°C (100.4°F). Arterial blood gas (ABG) obtained shows: pH 7.28, PaCO₂ 62 mmHg, PaO₂ 58 mmHg, HCO₃⁻ 26 mEq/L. The provider documents acute hypercapnic respiratory failure and orders noninvasive positive pressure ventilation (NIPPV) and nebulized bronchodilators; the respiratory therapist is en route.
You will complete 6 clinical judgment questions based on the client scenario. Questions appear one at a time. You cannot go back.
NGN 2026 • Physiological Integrity • Clinical Judgment Practice
Acute COPD Exacerbation with Hypercapnic Respiratory Failure