Editing Anatomy and Physiology – LPN Practice Questions (section)

==Question 8==
A licensed practical nurse notes that a patient who was previously alert has become restless and is picking at the bedsheets. The respiratory rate is 28 breaths per minute and the heart rate is 112 beats per minute. What should the nurse do '''first'''?
# Reorient the patient and raise all four side rails.
# Check the oxygen saturation and report the change to the registered nurse.
# Document the behavior as sundowning and continue to observe.
# Administer the prescribed as-needed sedative.

'''Answer:''' 2 (B). Check the oxygen saturation and report the change to the registered nurse.

''Rationale:'' Brain tissue has a very high oxygen requirement and no meaningful oxygen reserve, so a change in mental status is often the earliest sign of hypoxia. Restlessness with tachypnea and tachycardia is a classic early hypoxia pattern, and cyanosis is a very late sign. Collecting objective data and reporting promptly allows the registered nurse to assess and intervene. Option 1 does not address the physiologic cause, and raising all four side rails is generally considered a restraint. Option 3 assumes a behavioral explanation without ruling out a physiologic one. Option 4 could depress respirations further and worsen hypoxia.