Find the reversible cause first
This 78-year-old woman with pneumonia becomes newly restless and disoriented at night, tries to climb out of bed, and pulls at her IV line. A sudden change in attention and orientation in an older adult with an acute illness suggests delirium, and the first nursing task in delirium is to look for a cause that can be corrected quickly. The data point clearly to one: her ordered nasal cannula is lying on the pillow and her oxygen saturation is 88%. Hypoxia is both a likely cause of her confusion and an immediate threat to breathing, so putting the cannula back on and rechecking the saturation comes first.
Ruling out the other causes in the stem
The stem deliberately supplies data that exclude other common triggers of acute confusion. Her capillary blood glucose is 132 mg/dL (7.3 mmol/L), so hypoglycemia is not the cause. Her bladder is not distended, so urinary retention is unlikely. Her temperature is 37.6 °C, a low-grade fever that fits pneumonia but does not explain a sudden change on its own. Only the low saturation with the cannula off is both abnormal and immediately reversible.
| Possible cause | Data in the stem | Conclusion |
|---|
| Hypoxia | SpO2 88%, cannula off | Likely cause; correct now |
| Hypoglycemia | Glucose 132 mg/dL | Ruled out |
| Urinary retention | Bladder not distended | Ruled out |
| Fever or sepsis | 37.6 °C | Low-grade; keep monitoring |
Why the other appropriate actions follow
The stem says all four options are appropriate, so the question is about order. Reorientation and a calm presence help a delirious client, but they do not correct the hypoxia that is driving her behavior. Checking and sleeving the IV site protects the line, yet the line is not the immediate danger. Asking her daughter to stay at the bedside is an excellent alternative to restraint for the rest of the night, particularly because she is at high fall risk on the Morse Fall Scale (previous fall, secondary diagnosis, IV line, and impaired gait). Each of these follows once oxygen is restored and the saturation is confirmed.
Watch out! Do not reach for restraint or sedation in a newly confused older client before checking oxygenation, glucose, pain, bladder, and infection. Restraint increases agitation and fall injury, and sedatives can worsen both hypoxia and delirium.
Exam takeaway
Key point! When behavior changes suddenly, treat it as a physiological problem until proven otherwise. In a client with pneumonia and an SpO2 of 88% with the cannula off, the first action is to restore oxygen and reassess; safety measures, family presence, and reorientation then complete the plan.