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?

A. Metabolic acidosis

Metabolic acidosis is characterized by a low pH (< 7.35) and a decreased bicarbonate level (< 22 mEq/L). In this scenario, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not support a diagnosis of metabolic acidosis.

B. Respiratory acidosis

Respiratory acidosis occurs when there is an accumulation of carbon dioxide (PaCO2 > 45 mm Hg), leading to a decrease in pH (< 7.35). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), consistent with respiratory acidosis.

C. Metabolic alkalosis

Metabolic alkalosis is characterized by a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). In this scenario, the pH is low (7.22), and the bicarbonate level is also elevated (28 mEq/L), which does not support a diagnosis of metabolic alkalosis.

D. Respiratory alkalosis

Respiratory alkalosis occurs when there is a decrease in carbon dioxide (PaCO2 < 35 mm Hg), leading to an increase in pH (> 7.45). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), which is not consistent with respiratory alkalosis.

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.