A patient is admitted to the hospital with SOB. The nurse notices increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first?

Assess the patient; check to see if the oxygen is flowing correctly

Page the MD STAT

Put up the patient's side rails and apply soft restraints

Administer an IM sedative

Answer and Explanation

The Correct Answer is A

A. Assess the patient; check to see if the oxygen is flowing correctly:

This option involves assessing the patient's condition promptly, particularly focusing on the adequacy of oxygenation. Checking the oxygen delivery system ensures that the patient is receiving the prescribed oxygen therapy at the appropriate flow rate. In a patient with shortness of breath (SOB) and increasing confusion and combativeness, hypoxemia (low oxygen levels) could be a contributing factor. Therefore, assessing the oxygen delivery system is crucial to ensure proper oxygenation and address potential causes of the patient's symptoms.

B. Page the MD STAT:

Paging the MD STAT may be necessary after assessing the patient's condition, especially if the patient's symptoms indicate a medical emergency or require immediate intervention. However, in this scenario, the priority is to assess the patient's condition and address any immediate concerns related to oxygenation and respiratory status. While paging the healthcare provider may be necessary, it should not delay the initial assessment and interventions needed to stabilize the patient.

C. Put up the patient's side rails and apply soft restraints:

Applying side rails and soft restraints should not be the first action in response to the patient's symptoms. While patient safety is important, these measures should only be implemented after other interventions have been attempted, and there is a risk of harm to the patient or others due to agitation or combativeness. In this case, the patient's confusion and combativeness may be secondary to hypoxemia, so addressing oxygenation and assessing the patient's condition are the immediate priorities.

D. Administer an IM sedative:

Administering a sedative should not be the first action in this scenario. Sedation may be considered if the patient's agitation or combativeness poses a risk to their safety or interferes with assessment and treatment. However, the underlying cause of the patient's symptoms, such as hypoxemia, should be addressed first. Administering a sedative without addressing the potential cause of the patient's symptoms could mask important clinical indicators and delay appropriate treatment.

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Correct Answer is A

Explanation

A. Liver function tests

This is the correct choice. Pyrazinamide, a medication used in the treatment of tuberculosis, is known to potentially cause hepatotoxicity, which refers to liver damage or dysfunction. Therefore, clients prescribed pyrazinamide should undergo regular monitoring of liver function tests to assess for any signs of liver injury or impairment. Liver function tests typically include measurements of various enzymes and proteins produced by the liver, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin levels.

B. Gallbladder studies

Gallbladder studies are not typically indicated for clients taking pyrazinamide. While pyrazinamide can rarely cause hepatotoxicity, which may affect liver function, it is not known to specifically target or affect the gallbladder. Therefore, routine gallbladder studies are not necessary for clients taking pyrazinamide.

C. Thyroid function studies

Pyrazinamide is not known to directly affect thyroid function. Therefore, routine thyroid function studies are not indicated for clients taking pyrazinamide unless there are specific signs or symptoms suggesting thyroid dysfunction.

D. Blood glucose levels

Pyrazinamide is not known to directly affect blood glucose levels. Therefore, routine monitoring of blood glucose levels is not indicated for clients taking pyrazinamide unless there are specific reasons to suspect or monitor for diabetes mellitus or other conditions affecting blood glucose regulation.

A. Inspiratory stridor B. Expiratory wheeze C. Absence of breath sounds D. Coarse crackles

Correct Answer is C

Explanation

A. Inspiratory stridor

Inspiratory stridor is a high-pitched, musical sound heard during inspiration and is typically caused by turbulent airflow due to partial obstruction of the upper airway. It is commonly associated with conditions such as croup, epiglottitis, or anaphylaxis. While respiratory distress may occur in a pneumothorax, inspiratory stridor specifically suggests an upper airway obstruction rather than a pneumothorax.

B. Expiratory wheeze

Expiratory wheeze is a high-pitched, musical sound heard during expiration and is typically associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchiolitis. Wheezing occurs due to narrowing of the airways, leading to turbulent airflow during expiration. While a pneumothorax can cause respiratory distress, it is not typically associated with wheezing.

C. Absence of breath sounds

The absence of breath sounds over a particular area of the chest can indicate a pneumothorax. In a pneumothorax, air accumulates in the pleural space, causing partial or complete collapse of the lung and preventing it from making contact with the chest wall. This absence of breath sounds over the affected area is a classic finding in a pneumothorax and is crucial for its detection.

D. Coarse crackles

Coarse crackles are discontinuous, bubbling or popping sounds heard during inspiration and may be indicative of conditions such as pneumonia, pulmonary edema, or bronchiectasis. These crackles are typically heard when there is fluid or mucus in the airways. While a pneumothorax can cause respiratory distress, it does not typically produce crackles on auscultation.

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A patient is admitted to the hospital with SOB. The nurse notices increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first?

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