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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Notify the provider.

This choice suggests involving the healthcare provider immediately. While notifying the provider might eventually be necessary if the issue persists, it's not the initial action in this scenario. The nurse should first assess and troubleshoot the situation before escalating it to the provider.

B. Verify that the suction regulator is on.

This is the correct choice. When there is no bubbling in the suction control chamber of a chest tube, it may indicate that suction is not being applied properly. Verifying that the suction regulator is turned on and set to the correct level ensures that suction is being delivered to the chest tube.

C. Continue to monitor the client because this is an expected finding.

This choice is incorrect. The absence of bubbling in the suction control chamber is not an expected finding and suggests a potential problem with the suction system. Ignoring this finding without taking any action could lead to complications for the client.

D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.

Milking the chest tube is a technique used to maintain patency and promote drainage in chest tubes, but it should not be the first action when there is no bubbling in the suction control chamber. This action does not address the underlying issue of inadequate suction and may not be appropriate without first ensuring that suction is functioning correctly.

A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms. B. Place restrictions on visitation. C. Implement airborne precautions for clients who have influenza. D. Provide prophylactic antibiotics for clients who have been exposed to influenza

Correct Answer is B

Explanation

A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms.

While it's important for healthcare personnel to stay home when they have influenza symptoms to prevent transmission to residents and coworkers, restricting them to nondirect care activities for only 24 hours may not be sufficient. Healthcare personnel with influenza symptoms should follow institutional policies regarding sick leave and clearance to return to work, which typically involve staying home until they are no longer contagious.

B. Place restrictions on visitation.

During an influenza outbreak in a long-term care facility, it's crucial to include interventions to prevent further spread of the virus. Placing restrictions on visitation helps reduce the risk of introducing the virus from outside sources into the facility. Visitors may inadvertently bring the influenza virus with them, potentially exposing vulnerable residents and staff members.

C. Implement airborne precautions for clients who have influenza.

Influenza is primarily transmitted through respiratory droplets rather than through airborne transmission. Airborne precautions are not typically necessary for managing influenza in a long-term care facility. Standard precautions, including hand hygiene, respiratory hygiene/cough etiquette, and use of personal protective equipment, are sufficient for preventing transmission.

D. Provide prophylactic antibiotics for clients who have been exposed to influenza.

Influenza is a viral infection and is not treated with antibiotics. Prophylactic antibiotics are not indicated for preventing influenza. Antiviral medications may be used for prophylaxis in certain high-risk individuals or in outbreak settings, but their use should be based on recommendations from public health authorities and healthcare providers, not blanket administration to all exposed individuals.

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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?

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Explanation

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Correct Answer is B

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