After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
A. Call the physician
B. Document the patient’s status in his charts
C. Prepare oxygen treatment
D. Raise the side rails
Correct Answer: D. Raise the side rails
A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients’ safety.
Option A: Calling the physician would be unnecessary. These findings can be reported after ensuring the patient’s safety first.
Option B: After notifying the physician, the nurse should document these findings.
Option C: Oxygen treatment would be needed as ordered by the physician.