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Difficulty: MediumData Collection Techniques

A practical nurse (PN) is collecting baseline data on an 82-year-old client admitted to a medical-surgical unit after a fall. The PN notes that the client is suddenly restless, mildly confused, and has a respiratory rate of 28 breaths/min. Which action should the PN prioritize during data collection?

  1. Measure the client's oxygen saturation and auscultate lung soundsAnswer
  2. B
    Document the confusion as an expected age-related cognitive decline
  3. C
    Perform a comprehensive, independent physical assessment to diagnose the underlying cause
  4. D
    Prioritize assessing the client's pain level from the fall before evaluating respiratory status

Answer

The practical nurse should prioritize measuring the client's oxygen saturation and auscultating lung sounds.
In the presence of sudden restlessness, confusion, and tachypnea, the practical nurse must prioritize assessing for hypoxia. Measuring oxygen saturation and auscultating lung sounds are focused data collection techniques within the PN scope of practice that directly evaluate the client's respiratory status (Breathing) in accordance with the ABC framework.

Step-by-Step Solution

1
Identify the client's acute clinical changes.
The client is exhibiting sudden restlessness, mild confusion, and tachypnea (28 breaths/min).
Recognizing deviations from the baseline is the first step in determining which focused data collection technique is needed.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The client's elevated respiratory rate and new-onset restlessness strongly indicate a potential breathing or oxygenation deficit.
Physiological needs related to oxygenation are life-threatening and must take precedence over other assessments.
3
Select the appropriate focused data collection technique within the PN scope of practice.
Measuring oxygen saturation and auscultating lung sounds are chosen as the immediate actions.
These targeted techniques allow the PN to gather essential objective data about the client's respiratory status to report to the RN.

Key Concept

Focused Data Collection and ABC Prioritization
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Topics

Data Collection Techniques

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