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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Constipation
Constipation is not typically associated with obstructive sleep apnea. However, sleep disturbances and certain medications used to manage OSA may indirectly contribute to constipation in some cases.
B. Nausea
Nausea is not a common symptom of obstructive sleep apnea. While sleep disturbances may affect gastrointestinal function in some individuals, nausea is not a typical manifestation of OSA.
C. Headache
One of the common findings associated with obstructive sleep apnea (OSA) is headache. This occurs due to the repeated episodes of apnea (cessation of breathing) during sleep, which leads to intermittent hypoxia (low oxygen levels) and subsequent cerebral vasodilation. The vasodilation can trigger headaches, often described as morning headaches, upon waking up. These headaches are typically frontal and may be accompanied by other symptoms such as fatigue and irritability.
D. Hypotension
Hypotension (low blood pressure) is not a typical finding in obstructive sleep apnea. In fact, individuals with OSA are more likely to have hypertension (high blood pressure) due to the effects of repeated apnea episodes on the cardiovascular system, such as increased sympathetic activity and arterial stiffness.
Correct Answer is ["A","C","D","E"]
Explanation
Correct Answers:
A. Frequent oral hygiene is necessary:Steroid inhalers can increase the risk of oral thrush and other infections, so maintaining good oral hygiene is essential to minimize this risk.
C. Rinse and spit after inhalation of the medication:Rinsing the mouth and spitting after using a steroid inhaler helps to remove residual medication and reduce the risk of developing oral thrush.
D. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first:Administering a bronchodilator first helps open the airways, allowing the steroid medication to reach deeper into the lungs for more effective treatment.
E. Hold your breath for 10 seconds during inhalation of the medication:Holding the breath allows for better medication absorption in the lungs.
Incorrect Answer:
B. The inhaler should be used on a PRN basis only:Steroid inhalers are typically used on a regular schedule for long-term control of asthma or other respiratory conditions, rather than on a PRN (as needed) basis. PRN use is more applicable to rescue inhalers, like short-acting bronchodilators.
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