During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?
Administer supplemental oxygen to the client.
Check the position of the pulse oximeter probe and ensure it is properly attached.
Assess the client's airway for obstruction.
Notify the healthcare provider immediately.
The Correct Answer is B
A. Administering supplemental oxygen is appropriate if the low oxygen saturation is confirmed, but the nurse should first verify the accuracy of the reading to avoid unnecessary interventions.
B. Checking the position of the pulse oximeter probe and ensuring it is properly attached is the first step. Faulty probe placement or technical issues can cause inaccurate readings, so confirming the validity of the drop in SpO2 is essential before taking further action.
C. Assessing the client's airway for obstruction is critical if the low SpO2 is verified and no technical issues are found. However, this step follows confirming the accuracy of the pulse oximetry reading.
D. Notifying the healthcare provider is necessary if the drop in SpO2 is confirmed and persists despite initial nursing interventions, but it is not the first action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Flail chest occurs when multiple ribs are fractured in more than one location, creating a free-floating segment of the chest wall. This segment moves paradoxically during respiration, meaning it moves inward during inspiration and outward during expiration, which impairs effective breathing and oxygenation.
B. Paralysis of the chest wall may occur in conditions like spinal cord injuries but is not the defining characteristic of flail chest.
C. While decreased oxygenation can occur with flail chest due to impaired ventilation, the defining feature is the paradoxical movement of the fractured rib segment.
D. Weakness of the diaphragm can impair lung expansion, but this is characteristic of conditions like diaphragmatic paralysis, not flail chest.
Correct Answer is A
Explanation
A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.
B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.
C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.
D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.
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