A patient with chronic lung disease becomes newly drowsy. The respiratory rate is 26 per minute, the skin is cool, and the oxygen saturation is 84% on the prescribed oxygen. What should the nurse do first?
Correct answer: A. Assess airway and breathing while calling for urgent clinical support
- A. Assess airway and breathing while calling for urgent clinical support
- B. Remove the oxygen because drowsiness may indicate carbon dioxide retention
- C. Ask the patient to rest and repeat the oxygen saturation in 30 minutes
- D. Give a sedative to reduce anxiety and slow the respiratory rate
Explanation
New drowsiness with severe hypoxaemia and abnormal breathing indicates possible acute respiratory failure. The nurse must assess airway and breathing and obtain urgent support, while oxygen therapy is managed according to the patient's clinical response and prescription.
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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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