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 A
Explanation
A. Oral mucosa:
The oral mucosa, including the inside of the mouth, tongue, and lips, is a reliable indicator of cyanosis. Cyanosis appears as a bluish discoloration of these tissues due to decreased oxygen saturation in the arterial blood. Assessing the oral mucosa is an essential component of clinical examination, especially in patients with respiratory conditions like asthma, as it provides valuable information about oxygenation status.
B. Tip of the nose:
While the tip of the nose may exhibit cyanosis in some cases, it is not considered as reliable of an indicator as the oral mucosa. The nasal tip is more susceptible to external factors such as cold temperatures or poor circulation, which can cause temporary discoloration. Therefore, it may not always accurately reflect the oxygenation status of the patient compared to the oral mucosa.
C. Ear lobes:
Cyanosis may be observed in the ear lobes in cases of severe hypoxemia, but it is not as reliable of an indicator as the oral mucosa. The ear lobes are less commonly assessed for cyanosis compared to other areas such as the lips, nail beds, or oral mucosa. While cyanosis may be present in the ear lobes, it is not typically the primary site assessed for oxygenation status.
D. Eyelids:
Cyanosis is not typically observed in the eyelids and is not considered a reliable indicator of hypoxemia. The eyelids are not commonly assessed for cyanosis during clinical examinations. While the conjunctiva (the lining inside the eyelids) may appear pale in cases of severe anemia, it is not a specific sign of hypoxemia. Assessment of the oral mucosa, lips, and nail beds is preferred for evaluating oxygenation status in patients with respiratory conditions like asthma.
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.
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