A family member visits a client who is receiving intravenous antibiotics for a severe urinary tract infection. The family member approaches the practical nurse and states, "My father is acting very strangely. He does not know who I am and keeps trying to climb over the bed rails." Upon entering the room, the nurse notes the client is highly agitated and actively tugging at the intravenous tubing. Which action should the practical nurse take first?
- AInform the family member that sudden confusion is an expected complication of aging
- BSecure the client's wrists with protective devices to prevent intravenous line dislodgment
- Measure the client's pulse oximetry and current vital signsCevap
- DReorient the client to the hospital setting using a calm, soothing voice
Cevap
Measure the client's pulse oximetry and current vital signs.
The correct action is to measure the client's pulse oximetry and current vital signs. Sudden onset of confusion and agitation in a client with an infection is a key indicator of physiological decompensation, such as hypoxia or early sepsis. The practical nurse must first collect physiological data to identify if there is an immediate, life-threatening airway, breathing, or circulation (ABC) issue before attempting any secondary behavioral interventions.
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Prioritization of physiological assessment in acute delirium