Examkin

Question

Difficulty: MediumPhysiological Adaptation

Family members call the nurse to the room of an older adult client who is receiving intravenous antibiotics for severe pneumonia. The client has suddenly become agitated, confused about their surroundings, and is pulling at the intravenous tubing. Baseline mental status is alert and oriented. Which action should the nurse prioritize?

  1. Check the client's oxygen saturation and respiratory rate.Answer
  2. B
    Review the admission assessment for a history of dementia.
  3. C
    Apply soft wrist restraints to prevent removal of the tubing.
  4. D
    Contact the primary healthcare provider to request an order for a sedative.

Answer

Check the client's oxygen saturation and respiratory rate.
Sudden onset of restlessness, agitation, and confusion in a client with a respiratory infection is a classic early sign of hypoxia. The nurse must prioritize airway, breathing, and circulation (ABC) by assessing the client's oxygen saturation and respiratory status before assuming the behavior is due to age, psychiatric issues, or requiring physical restraints.

Step-by-Step Solution

1
Analyze the client's symptoms and baseline status.
The client has a sudden onset of agitation and confusion, which is a significant change from their alert and oriented baseline.
Identifying an acute change in condition is the first step in clinical judgment.
2
Determine the most life-threatening potential cause for the symptoms based on the client's diagnosis.
The client has severe pneumonia, making hypoxia the most critical potential cause of sudden restlessness and confusion.
Airway, Breathing, and Circulation (ABCs) must be prioritized in emergent situations.
3
Select the intervention that addresses the highest priority concern.
Checking oxygen saturation and respiratory rate directly assesses for hypoxia.
Data collection related to ABCs precedes other interventions like restraints, medications, or provider notification.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABCs) and recognition of hypoxia in acute respiratory illness.
Rate this question

Topics

Physiological Adaptation

More questions from this topic