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Zorluk: KolayPhysiological Adaptation

A practical nurse (PN) is caring for an 82-year-old client who is receiving oxygen therapy for a severe respiratory infection. The client suddenly becomes highly restless, confused, and attempts to pull off the oxygen cannula. Which action should the PN take first?

  1. A
    Explain to the family that sudden confusion is a normal part of the aging process.
  2. B
    Administer the prescribed as-needed analgesic to help the client relax.
  3. Check the client's oxygen saturation level using a pulse oximeter.Cevap
  4. D
    Apply bilateral wrist restraints to prevent the client from removing the oxygen equipment.

Cevap

Check the client's oxygen saturation level using a pulse oximeter.
The correct action directly evaluates the client's respiratory status. In older adults, sudden restlessness, agitation, and confusion are frequently the earliest signs of systemic hypoxia. Using the ABC (Airway, Breathing, Circulation) framework, the practical nurse must first gather data regarding oxygenation to determine if a life-threatening complication is occurring.

Adım Adım Çözüm

1
Identify the sudden change in the client's condition (restlessness and confusion).
Recognize that these are neurological manifestations of a potential physiological compromise.
Early identification of subtle changes helps prevent severe complications.
2
Correlate the client's symptoms with their primary diagnosis (respiratory infection).
Determine that impaired gas exchange and resulting hypoxia are highly probable.
Restlessness is often the first clinical sign of hypoxia, especially in older adults.
3
Apply the ABC (Airway, Breathing, Circulation) priority framework.
Select the action that directly assesses the client's breathing and oxygenation status.
Physiological needs related to oxygenation always take precedence over comfort measures or physical restraints.

Anahtar Kavram

Early recognition of hypoxia and prioritization of ABCs (Airway, Breathing, Circulation)
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Physiological Adaptation

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