A patient recovering from surgery is showing early signs of hypoxia with occasional confusion and restlessness. What is the best nursing intervention?
Increase supplemental oxygen and reassess the patient.
Apply restraints for patient safety due to restlessness.
Notify the family about the change in mental status.
Document the findings and observe for further deterioration.
The Correct Answer is A
A. Increase supplemental oxygen and reassess the patient: Restlessness and confusion are classic early clinical manifestations of cerebral hypoxia. Increasing the fraction of inspired oxygen immediately addresses the physiological deficit at the base of Maslow's hierarchy. Reassessment ensures the intervention is effective in improving oxygen saturation and mental status.
B. Apply restraints for patient safety due to restlessness: Restraints are a last resort and are contraindicated if the patient's behavior is caused by a treatable physiological crisis like hypoxia. Restricting movement can increase agitation and further increase oxygen demand. The priority must be treating the underlying cause of the restlessness.
C. Notify the family about the change in mental status: Informing the family is a communication task that follows immediate clinical intervention. It does not address the life-threatening lack of oxygen that is causing the confusion. The patient's physical stability must be managed before administrative or family communication occurs.
D. Document the findings and observe for further deterioration: Passive observation in the presence of early hypoxia allows the patient's condition to worsen into respiratory arrest. Documentation is a legal requirement but should never delay active nursing intervention for an acute physiological change. Immediate action is required to prevent further decline.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pulmonary Embolism: This condition involves an acute mechanical obstruction of the pulmonary vasculature, usually by a thrombus. While it causes sudden shortness of breath and tachypnea, it does not typically produce a prolonged expiratory phase or diffuse wheezing. Its hallmark is a ventilation-perfusion mismatch without primary airway obstruction.
B. Asthma: This obstructive airway disease is characterized by reversible bronchoconstriction, mucosal edema, and mucus hypersecretion. The narrowed diameter of the lower airways increases resistance, making it particularly difficult for air to exit the lungs during expiration. This physiological resistance results in the classic prolonged expiratory phase and audible wheezing.
C. Pleural Effusion: An accumulation of fluid in the pleural space compresses the underlying lung tissue, leading to diminished breath sounds and dullness to percussion. It acts as an extrinsic restrictive process rather than an intrinsic obstructive one. It does not typically cause the prolonged expiratory whistling characteristic of small airway narrowing.
D. Pneumonia: This inflammatory process involves the consolidation of the alveoli with exudate and debris, which impairs gas exchange but does not primarily obstruct the small airways. Auscultatory findings usually include crackles or bronchial breath sounds over the area of consolidation. It does not cause the diffuse expiratory delay seen in bronchospastic disorders.
Correct Answer is A
Explanation
A. Optimizing gas exchange:Emphysema involves the irreversible destruction of alveolar walls and permanent enlargement of air spaces, which severely impairs the surface area for gas exchange. The primary goal of care is to maximize the patient's ability to oxygenate tissues and remove carbon dioxide. This addresses the core pathophysiological defect of the disease.
B. Managing acute infections:While emphysema patients are prone to secondary infections, the primary chronic focus is on respiratory mechanics and gas exchange. Infection management is a periodic necessity rather than the defining daily goal of care for emphysema. The plan of care focuses on long-term pulmonary rehabilitation.
C. Controlling chest pain:Chest pain is not a hallmark symptom of emphysema; rather, patients experience dyspnea and air hunger. If chest pain occurs, it may indicate a complication like a spontaneous pneumothorax or myocardial ischemia. It is not the primary focus of standard emphysema management.
D. Reducing fluid overload:Fluid overload is more characteristic of right-sided heart failure (cor pulmonale) or renal failure. While emphysema can lead to heart failure, the initial and primary focus remains on the lung parenchyma and gas exchange. Fluid management is a secondary concern related to potential cardiovascular complications.
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