Oxygen Dissociation Curve

Which of the following factors causes a RIGHT shift of the oxygen dissociation curve, indicating decreased hemoglobin affinity for oxygen?

A 52-year-old man with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Arterial blood gas shows: pH 7.32, PaCO₂ 62 mmHg, HCO₃⁻ 32 mEq/L, PaO₂ 58 mmHg. His hemoglobin is 16 g/dL (elevated due to chronic hypoxemia). Despite supplemental oxygen therapy, his tissue oxygen delivery remains suboptimal. Which factor is primarily responsible for facilitating oxygen unloading to tissues in this patient's setting?

Which of the following is the most common cause of a rightward shift of the oxygen-haemoglobin dissociation curve in a patient with chronic obstructive pulmonary disease?

Regarding factors that affect the oxygen dissociation curve of hemoglobin, all of the following cause a rightward shift (increased P50) EXCEPT:

A 52-year-old man with chronic obstructive pulmonary disease (COPD) and cor pulmonale presents with acute exacerbation. ABG shows: pH 7.32, PaCO₂ 58 mmHg, HCO₃⁻ 28 mEq/L, PaO₂ 52 mmHg on room air. He is drowsy but arousable. Chest X-ray shows hyperinflation without acute infiltrate. Which is the most appropriate immediate next step in management?