A nurse is planning care for a client who states they are anxious concerning abdominal surgery. Which of the following actions should the nurse take?

Choice A reason: Attending to personal hygiene improves comfort and prevents infection but is not the highest priority. Safety, including preventing falls or medication errors, prevents immediate harm, as hygiene issues pose less urgent risks, making this a secondary intervention compared to ensuring client safety.

Choice B reason: Ensuring client safety is the priority, preventing immediate harm like falls, medication errors, or equipment-related injuries. Safety is foundational, as unsafe conditions can lead to life-threatening complications, making this the most critical intervention to prioritize in any clinical setting for client well-being.

Choice C reason: Meeting psychosocial needs supports emotional well-being but is secondary to safety. Unaddressed safety risks, like falls, pose immediate physical harm, whereas psychosocial issues have longer-term impacts, making safety the priority over emotional or social support in clinical care.

Choice D reason: Providing patient-focused care ensures individualized treatment but is less urgent than safety. Safety prevents immediate harm, like falls or errors, while patient-focused care enhances outcomes over time, making it a secondary priority compared to ensuring the client’s physical safety.

Choice A reason: Anxiety and restlessness indicate ineffective oxygen therapy, as they suggest persistent hypoxia or hypercapnia. The brain senses inadequate oxygenation, triggering a stress response, indicating the need for adjusted oxygen delivery or investigation into underlying respiratory issues, making this a sign of therapy failure.

Choice B reason: Pink, warm skin indicates adequate oxygenation and perfusion, suggesting effective oxygen therapy. Cyanosis or cool skin would signal hypoxia. This finding reflects successful correction of oxygen deficits, making it an incorrect choice for indicating ineffective therapy in this client with supplemental oxygen.

Choice C reason: A heart rate of 58 (bradycardia) is not a primary indicator of ineffective oxygen therapy. Severe hypoxia typically causes tachycardia, while bradycardia may reflect other issues like medication effects, not directly oxygen therapy failure, making it less relevant in this context.

Choice D reason: A respiratory rate of 36 (tachypnea) indicates ineffective oxygen therapy, as rapid breathing reflects the body’s attempt to compensate for hypoxia or hypercapnia. This suggests insufficient oxygen delivery, requiring adjustment of oxygen flow or evaluation for respiratory issues, marking therapy failure.

Choice E reason: Use of accessory muscles indicates ineffective oxygen therapy, reflecting increased work of breathing due to persistent hypoxia or airway obstruction. Muscles like the sternocleidomastoid are recruited when primary respiratory muscles fail to maintain adequate oxygenation, signaling the need for immediate intervention.