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 A

Explanation

A. The patient's Spo2 is 97% on 2L NC:

This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.

B. The patient appears comfortable:

While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.

C. The patient is coughing up copious white sputum:

The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.

D. The patient is able to move out of bed without difficulty:

The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.

A. Pigeon B. Funnel C. Kyphotic D. Barrel

Correct Answer is D

Explanation

A. Pigeon

A pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs, resulting in a pigeon-like appearance of the chest. This deformity is not typically associated with COPD.

B. Funnel

A funnel chest, also known as pectus excavatum, is a deformity of the chest characterized by a depression or concavity in the sternum, resulting in a funnel-like appearance of the chest. This deformity is not typically associated with COPD.

C. Kyphotic

Kyphosis refers to an exaggerated forward curvature of the thoracic spine, leading to a hunched or rounded upper back. While individuals with severe COPD may develop kyphosis due to chronic respiratory muscle fatigue and increased work of breathing, kyphotic curvature is not specific to COPD and can occur in other conditions as well.

D. Barrel

In COPD (Chronic Obstructive Pulmonary Disease), the client's chest may take on a barrel shape. This is characterized by an increase in the anterior-posterior diameter of the chest, resulting in a more rounded appearance similar to that of a barrel. This change in chest shape is due to hyperinflation of the lungs, which occurs as a result of air trapping and increased residual volume in the lungs, common in COPD.

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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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