A patient suddenly becomes confused and restless. Assessment findings include BP 150/90, Pulse 110, RR 24…

Question

A patient suddenly becomes confused and restless. Assessment findings include BP 150/90, Pulse 110, RR 24, SpO2 92%, and RBS 2.8 mmol/L. The nurse is alone. What should the nurse do FIRST?

ScanSolve AI Tutor · Accepted Answer

Step 1: Review assessment findings. Patient suddenly confused (was stable 10 minutes ago). BP: 150/90 mmHg (elevated). Pulse: 110 bpm (tachycardia). Respiratory rate: 24 cpm (tachypnea). Oxygen saturation: 92% on room air (hypoxemia). Blood glucose: 2.8 mmol/L (severe hypoglycemia; normal 4.0--7.8 mmol/L). Nurse alone at station; staff attending emergency elsewhere. Step 2: Identify primary issue and risks. Severe hypoglycemia causing confusion, tachycardia, tachypnea, hypoxemia. Risks: further deterioration (seizure, coma), falls/injury (confusion), aspiration if oral intake. Step 3: Apply nursing priorities (ABCs first, then safety; call help if alone with unstable patient). ABCs intact but compromised (hypoxemia). Immediate glucose needed, but nurse alone cannot safely administer IV/oral, monitor, and manage potential decline simultaneously. Step 4: Evaluate options for FIRST action. A. Administer 50% dextrose IV: Requires IV access (not indicated); insertion/bolus takes time; unsafe alone. B. Administer oral 50% dextrose and observe: Incorrect--50% dextrose is IV only (hyperosmolar, GI risks); confused patient risks aspiration; oral glucose (juice/gel) for alert patients only. D. Place in safe position and recheck vital signs: Promotes safety but not FIRST (vitals recent); delays help/treatment. Step 5: Select FIRST action. C. Call for help--activates team (rapid response/code); essential when alone with unstable patient; allows concurrent safety measures/treatment. C

A patient suddenly becomes confused and restless. Assessment findings include BP 150/90, Pulse 110, RR 24, SpO2 92%, and RBS 2.8 mmol/L. The nurse is alone. What should the nurse do FIRST?

Step-by-step solution

Review assessment findings.

Identify primary issue and risks.

Apply nursing priorities (ABCs first, then safety; call help if alone with unstable patient).

Evaluate options for FIRST action.

Select FIRST action.

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