An older adult client with a history of congestive heart failure and chronic bronchitis is receiving inpatient care. The practical nurse observes that the client, who was alert and oriented two hours prior, has suddenly become highly agitated, is attempting to climb over the bed rails, and is unable to answer simple questions. Which of the following actions should the practical nurse prioritize?
- AExplain to the family that sudden confusion is an expected reaction to hospitalization for older adults.
- BAdminister the prescribed as-needed analgesic to help relieve the client's severe agitation.
- Apply a pulse oximeter to evaluate the client's current oxygen saturation level.Cevap
- DPlace physical restraints on the client immediately to prevent a potential fall from the bed.
Cevap
The practical nurse should prioritize applying a pulse oximeter to evaluate the client's current oxygen saturation level.
The correct action is to apply a pulse oximeter. In clinical practice, sudden onset of restlessness, agitation, or confusion—especially in a client with cardiopulmonary comorbidities—is one of the earliest signs of hypoxia. Using the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize assessing respiratory status before implementing any other interventions.
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Prioritization of Airway and Breathing (ABCs) in Acute Decompensation