An older adult on the first postoperative day becomes suddenly inattentive and disoriented. The confusion fluctuates during the shift. Which action should the nurse take first?
1Apply wrist restraints to prevent the client from leaving the bed
2Administer the prescribed sedative before completing an assessment
3Turn off the lights and limit all conversation until morning
4Assess oxygen saturation and evaluate for reversible causes now✓ Correct answer
Explanation
Sudden fluctuating inattention is consistent with delirium. The nurse should first assess for and address reversible contributors such as hypoxia, infection, pain, medications, dehydration, or metabolic disturbance.
Quick answer Assess oxygen saturation and look for reversible causes. Delirium is an acute brain-function change that often signals an underlying physiologic problem requiring prompt correction.
Why this is correct The sudden onset, inattention, and fluctuation distinguish delirium from a stable chronic cognitive disorder. Hypoxia and other reversible stressors can worsen rapidly, so assessment comes before sedation or restrictive measures.
Easy analogy or mental picture Delirium is like a warning light on a dashboard: first check what system is failing instead of covering the light. The analogy highlights an underlying cause, but a structured delirium assessment and individualized safety measures are still needed.
Memory hook Acute plus fluctuating confusion means search for a reversible cause, beginning with oxygenation.
NCLEX decision rule When postoperative confusion begins suddenly and fluctuates, treat it as delirium and assess physiologic causes first. Support orientation and safety while avoiding reflex sedation, isolation, or restraints unless a specific immediate indication exists.
Why the other choices are wrong Restraints can worsen agitation and injury risk. Sedation can mask the cause, while darkness and isolation increase disorientation rather than correcting hypoxia, infection, medication effects, or metabolic problems.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
NICE: Delirium Prevention, Diagnosis and ManagementNational Institute for Health and Care Excellence