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Difficulty: MediumPhysiological Adaptation

During a scheduled safety check, the practical nurse finds a client with a history of chronic obstructive pulmonary disease (COPD) and mild dementia attempting to pull off their oxygen nasal cannula. The client appears highly restless and agitated. Current vital signs indicate a heart rate of 112 beats/min, respirations of 28 breaths/min, and an oxygen saturation of 85% on 2 L/min. What is the priority action for the practical nurse to take?

  1. A
    Administer a prescribed as-needed (PRN) analgesic to help calm the client's agitation.
  2. B
    Document the agitation as an expected manifestation of the client's underlying dementia.
  3. Elevate the head of the client's bed and immediately verify that the oxygen system is functioning properly.Answer
  4. D
    Contact the healthcare provider to obtain an immediate prescription for soft wrist restraints.

Answer

The priority action is to elevate the head of the bed and ensure the oxygen delivery equipment is working correctly.
Restlessness, tachycardia, and tachypnea are early signs of hypoxia. The priority is to address the client's airway and breathing (ABCs). Elevating the head of the bed promotes maximum lung expansion, and checking the oxygen equipment ensures the client is actually receiving the prescribed oxygen. These are immediate, independent nursing actions that directly treat the underlying problem.

Step-by-Step Solution

1
Analyze the clinical cues from the scenario.
The client is exhibiting restlessness, agitation, tachypnea (28 breaths/min), tachycardia (112 beats/min), and hypoxia (SpO2 85%).
Recognizing early signs of hypoxia is essential for safe and effective client care.
2
Prioritize interventions using the ABC (Airway, Breathing, Circulation) framework.
Airway and breathing are the immediate priorities over secondary concerns like behavioral symptoms or pain.
Hypoxia is a life-threatening condition that requires prompt physiological intervention.
3
Select the most appropriate, independent nursing action within the practical nurse's scope of practice.
Positioning the client in a high-Fowler's position and verifying the oxygen flow directly supports breathing and oxygenation.
These actions are rapid, within the practical nurse scope, and directly address the physiological cause of the client's distress.

Key Concept

Early Signs of Hypoxia and ABC Prioritization
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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