A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first?
a. Notify the health care provider.
b. Assess the client's pulse oximetry.
c. Document the observation.
d. Raise the head of the bed.
B
Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.
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