medium · NCLEX-RN management
A client on a medical-surgical unit becomes suddenly confused, restless, and is found trying to climb out of bed.
Which action should the nurse take first?
- Administer a prn dose of haloperidol as prescribed for agitation and behavioral control.
- Apply soft wrist restraints and notify the provider to obtain a prescription for the restraints.
- Ask the UAP to sit with the client and provide constant observation until the family arrives.
- Assess the client's oxygen saturation level (SpO2) and perform a focused neurological evaluation.
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