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?

Question 1

Answer · 2026-03-21T21:48:08.332Z

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

Question 2

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?

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