The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.

Complete the following sentence by using the list of options.

The nurse should first plan to 

dropdown

and then

dropdown

.

This question focuses on prioritizing care for an older adult postoperative client showing signs of severe infection and acute delirium. The client has a surgical site that is warm, inflamed, and draining thick yellow discharge, along with fever, hypotension, tachycardia, and elevated WBC count, all indicating likely postoperative wound infection progressing toward sepsis. In addition, the client is exhibiting acute confusion, visual hallucinations (“spiders crawling”), and disorientation, consistent with delirium, likely secondary to infection. Priority nursing actions focus first on treating the underlying life-threatening cause, followed by environmental interventions to reduce sensory overload and agitation.

Rationale for correct choices:

• Contact the provider for an antibiotic prescription: The client shows clear signs of a severe postoperative wound infection, including fever, leukocytosis, hypotension, tachycardia, and purulent drainage from the surgical site. These findings suggest systemic infection with possible progression to sepsis, which requires urgent antimicrobial therapy. The history of penicillin anaphylaxis is also critical for guiding safe antibiotic selection. Prompt provider notification is essential to initiate broad-spectrum antibiotics and prevent further hemodynamic deterioration.

• Dim the lights: The client is experiencing acute delirium, evidenced by fluctuating confusion, hallucinations, and disorientation. Dimming the lights helps reduce sensory overstimulation and can decrease the intensity of visual hallucinations. A calm, low-stimulation environment is a key nonpharmacologic intervention for managing delirium. This intervention promotes orientation, reduces agitation, and enhances client safety in the ICU setting.

Rationale for incorrect choices:

• Ask the client’s partner to leave the room: The presence of a familiar person is beneficial in reducing delirium-related anxiety and confusion. Family members provide reassurance, orientation cues, and emotional support, which can help stabilize cognition. Removing the partner could worsen agitation, fear, and hallucinations. Therefore, family presence should be encouraged rather than restricted.

• Increase the volume on the television: Increasing auditory stimulation is inappropriate for a client experiencing acute delirium. Excess noise can worsen confusion, agitation, and perceptual disturbances. Clients with delirium benefit from a calm, quiet environment with minimal unnecessary stimulation. Increasing the television volume would likely exacerbate symptoms.

• Assist with elimination: Although elimination needs are important, this is not the priority intervention in the context of suspected sepsis and acute delirium. The immediate concern is infection management and stabilization of the client’s hemodynamic status. While toileting assistance may be provided as needed, it does not address the life-threatening underlying condition. Priority must remain on treating infection and reducing delirium triggers.

• Place the client in 4-point restraints: Restraints are not first-line management for delirium and should only be considered after all less restrictive interventions have failed. In this case, the client’s agitation is likely driven by infection and environmental confusion. Restraints may increase agitation, worsen delirium, and pose risks such as injury or decreased circulation. The focus should be on treating the cause and providing a safe, calm environment.