A patient receiving oxygen becomes restless, confused and cyanotic around the lips. Which assessment should the nurse perform first?
Correct answer: A. Check the patient's airway and breathing
- A. Check the patient's airway and breathing
- B. Ask about the patient's usual sleep pattern
- C. Inspect the skin for a pressure injury
- D. Review the patient's usual dietary intake
Explanation
Restlessness, confusion and cyanosis suggest worsening oxygenation, so airway and breathing are assessed first. The ABC principle gives breathing-related threats priority over routine skin and nutrition assessments.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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