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Difficulty: MediumPhysiological Adaptation

A 78-year-old client is receiving treatment for bacterial pneumonia. During afternoon rounds, the practical nurse (PN) observes that the client, who was previously alert, has suddenly become highly restless, confused, and is actively trying to remove their intravenous (IV) catheter. The client's respiratory rate has increased to 26 breaths/min. Which action should the PN take first?

  1. Measure the client's current oxygen saturation level.Answer
  2. B
    Verbally reorient the client and dim the lights to decrease stimulation.
  3. C
    Contact the healthcare provider to request an as-needed sedative medication.
  4. D
    Apply bilateral soft wrist restraints to protect the intravenous access.

Answer

The correct action is to measure the client's current oxygen saturation level, as sudden confusion and restlessness strongly indicate acute hypoxia.
The correct action is to measure the client's oxygen saturation because sudden restlessness, confusion, and an increased respiratory rate in a client with pneumonia are classic, early indicators of hypoxia. In the nursing process and ABC prioritization, assessing the client's breathing and oxygenation status is paramount before implementing symptom-management interventions.

Step-by-Step Solution

1
Identify the sudden change in mental status (restlessness and confusion) and increased respiratory rate.
Recognition that the client's condition has acutely decompensated.
Sudden neurological changes often have a physiological, rather than psychological, origin.
2
Correlate the client's diagnosis (bacterial pneumonia) with the new symptoms.
Hypoxia is identified as the most probable cause of the sudden agitation.
Pneumonia impairs gas exchange, leading to decreased oxygen levels in the blood and brain.
3
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Gathering data on the client's oxygenation status is prioritized over managing the behavioral symptoms.
Addressing a potential breathing and oxygenation deficit is critical to preventing severe physiological injury.

Key Concept

Prioritization of ABCs in Acute Hypoxia
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Topics

Physiological Adaptation

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