While assessing an older adult client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, and restless. Which is the nurse's first action?
a. Administer oxygen via nasal cannula.
b. Apply restraints and ask for a sitter.
c. Slow the IV flow rate.
d. Discontinue the pain medication.
A
The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administra-tion can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Pain medication most likely would not cause the client to be restless. The IV rate is not related.
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