After several days of sedation and mechanical ventilation, a client is successfully extubated and is placed on oxygen 40% by face mask. While making rounds, the nurse finds that the client is confused and is attempting to get out of bed. Vital signs are temperature 99.2° F (37.3° C), heart rate 112 beats/minute, respirations 16 breaths/minute, blood pressure 100/70, and oxygen saturation 98%. Which action should the nurse take?

Rationale: A. Administer a benzodiazepine: Sedation may worsen respiratory drive and cause hypoventilation in a recently extubated client. Benzodiazepines should only be used if agitation persists after addressing environmental and safety concerns, and under provider direction. B. Apply wrist restraints: The client’s confusion and attempt to climb out of bed pose a high risk for accidental self-injury or removal of oxygen equipment. Applying soft wrist restraints temporarily ensures safety while further assessing for causes of confusion and notifying the healthcare provider. C. Notify the rapid response team: The client is hemodynamically stable with normal oxygen saturation and respiratory effort. Calling the rapid response team is unnecessary unless there is evidence of acute deterioration, such as respiratory distress or loss of consciousness. D. Increase oxygen to 60%: The oxygen saturation of 98% indicates adequate oxygenation at the current FiO₂. Increasing oxygen unnecessarily could suppress respiratory drive and does not address the underlying cause of confusion or unsafe behavior.