A patient is admitted with complaints of shortness of breath. The nurse observes that patient becomes confused and combative. Which of the following nursing action to be initiated on a priority basis?

1. A

   Ensure the oxygen is flowing correctly

2. B

   Page the physician stat

3. C

   Put up patient's side rails and apply soft restraints

4. D

   Administer an intramuscular sedative

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2019

Explanation

• The patient's sudden onset of confusion and combativeness are hallmark signs of cerebral hypoxia, a life-threatening condition where the brain isn't receiving enough oxygen.
• The nursing priority is always to follow the ABCs: Airway, Breathing, and Circulation. The patient's problem is a critical issue with 'Breathing'.
• Ensuring the oxygen delivery system is functioning correctly is the most immediate and direct action to address the cause of hypoxia. This could involve checking for kinked tubing, ensuring the oxygen source is on, or verifying the mask/cannula is properly placed.
• This intervention is rapid, within the nurse's scope of practice, and can quickly reverse a life-threatening situation.

Why Other Options Were Wrong

• Option B: While the physician must be notified, this is not the first action. The nurse should perform an immediate, life-saving intervention within their scope of practice first. Delaying action to wait for a physician could be fatal.
• Option C: This action addresses the symptom (combativeness) and patient safety, but it does not treat the underlying physiological cause (hypoxia). The priority is to treat the life-threatening condition, not just manage its behavioral symptoms.
• Option D: This is a dangerous and contraindicated action. Administering a sedative to a hypoxic patient can suppress their respiratory drive, worsening hypoxia and potentially leading to respiratory arrest.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing care for a patient with hypoxia to guide bedside assessment, documentation, and the next nursing action.
• A change in mental status (restlessness, confusion, agitation) is often the earliest and most sensitive indicator of hypoxia. Nurses must be vigilant for these subtle changes.
• The ABC (Airway, Breathing, Circulation) framework is the cornerstone of prioritization in nursing. Always address life-threatening physiological needs before psychosocial needs or safety measures that don't correct the root cause.
• Never sedate a confused or agitated patient without first ruling out hypoxia. This is a critical patient safety principle.

How to Approach the Question

• First, analyze the clinical scenario: a patient with shortness of breath develops an acute change in mental status (confusion, combativeness).
• Connect these signs and symptoms. Recognize that in a patient with a respiratory complaint, confusion and agitation are classic signs of hypoxia (lack of oxygen to the brain).
• Apply the ABC (Airway, Breathing, Circulation) prioritization framework. The patient's problem is a critical 'Breathing' issue.
• Evaluate each option based on the ABC framework. Ask yourself, 'Which action most directly and immediately addresses the patient's oxygenation?'
• The action of checking the oxygen supply directly addresses 'Breathing'.
• Eliminate other options. Paging the doctor is a secondary action. Restraints and sedation address symptoms, not the cause, and sedation is dangerous in this context.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing care for a patient with hypoxia.
• Stem keywords: shortness of breath, confused, combative, nursing action, priority
• Lead-in keywords: priority basis
• Clinical cues: A patient with a known respiratory issue (shortness of breath) developing an acute change in mental status (confusion, combativeness) is a red flag for hypoxia.

Question ID

QDZyoaj-FWQ3l1OCMxB3PQ

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 196-198