Question

An older adult male to had an abdominal cholecystectomy has become increasingly confused and disoriented over is past 24 hours. He is found wandering into ano isrclient’sroom and is return to his room by is unlicensed assistive personnel (UAP). What actions should is nurse take? (Select all that apply).

a)Apply soft upper limb restrains and raise all four bed rails
b)Report mental status change to is healthcare provider
c)Assess isclient’sbreath sounds and oxygen saturation
d)Assign is UAP to re-assess isclient’srisk for falls
e)Review isclient’smost recent serum electrolyte values

Answer 1

The nurse should report the mental status change, assess the patient's respiratory function, and review serum electrolyte values to address the confusion and disorientation of an older adult male post-cholecystectomy.

Step-by-step explanation:

When an older adult male exhibits increased confusion and disorientation following an abdominal cholecystectomy, the nurse should take several actions to ensure patient safety and address potential complications. These actions include:

• Reporting the mental status change to the healthcare provider, as sudden changes could indicate a serious underlying issue such as infection, electrolyte imbalance, or medication side effects.
• Assessing the patient's breath sounds and oxygen saturation to rule out respiratory complications, which are common after surgery and can cause confusion if oxygen levels are low.
• Reviewing the patient's most recent serum electrolyte values as electrolyte imbalances can contribute to confusion and disorientation.

It is important to note that applying physical restraints and raising all four bed rails without proper evaluation and authorization may not be appropriate and could pose a safety risk. Assigning a UAP to re-assess the patient's risk for falls should only be done under the supervision of a licensed nurse and within the UAP's scope of practice. The primary concern is to identify the underlying cause of the patient's altered mental status and address it accordingly.