What should be the priority action for a nurse caring for a client with pneumonia who is in restraints and showing confusion?

In situations where a client is experiencing confusion, especially with a medical condition such as pneumonia, ensuring their safety and monitoring their condition becomes paramount. Obtaining vital signs is the appropriate priority action because vital signs provide critical information about the client’s current physiological status. In pneumonia cases, changes in vital signs such as elevated heart rate, increased respiratory rate, fever, or low oxygen saturation can indicate a worsening of the condition, necessitating immediate medical attention.

While other actions such as assessing skin integrity, releasing restraints, and auscultating lung sounds are important components of care, they may not address the immediate medical needs of the patient experiencing confusion and potential respiratory distress. Vital sign assessment forms the basis for further interventions and can guide the nurse in prioritizing actions based on the client's current condition.