A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take?
a. Stays with the client and replaces the oxygen mask
b. Asks the client's spouse to hold the oxy-gen mask in place
c. Restrains the client per facility policy
d. Contacts the health care provider and re-quests sedation
A
Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.
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