A patient receiving a sedative becomes difficult to rouse. The respiratory rate is 10 per minute and oxygen saturation has fallen from 97% to 89%. What should the nurse do first?
Correct answer: A. Assess airway and breathing while calling for urgent help
- A. Assess airway and breathing while calling for urgent help
- B. Ask the patient to take several deep breaths
- C. Document the sedation score and reassess in 30 minutes
- D. Give the next prescribed dose to prevent withdrawal symptoms
Explanation
Reduced consciousness, slow breathing, and falling oxygen saturation indicate possible respiratory depression. The nurse must immediately assess airway and breathing and summon urgent assistance. Waiting or giving further sedative could worsen the patient's condition.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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