The nurse cares for a client with a history of cardiac dysrhythmias. Which vital sign should the nurse prioritize when conducting the assessment?

A. Furuncle is a localized bacterial infection of a hair follicle, often presenting as a small, tender, red nodule with possible pus. While furuncles can occur on the outer ear, the client’s diffuse redness, swelling, and purulent discharge along with tragus pain are more consistent with a broader infection rather than a single follicle, so this is less likely.

B. Otitis externa, also known as “swimmer’s ear,” is an infection of the external auditory canal. It often develops after swimming or prolonged moisture exposure, which explains the onset the day after swimming. Classic signs include redness, swelling, scaling, crusting of the pinna, purulent discharge, and pain that worsens with movement of the pinna or pressure on the tragus. The client’s presentation matches these hallmark features, making this the correct answer.

C. Otitis media is an infection of the middle ear, typically presenting with ear pain, fever, hearing loss, and sometimes fluid behind the tympanic membrane, but it usually does not cause pain when the pinna or tragus is touched, and the external ear often appears normal. Therefore, otitis media is unlikely.

D. Excessive cerumen (earwax buildup) can cause fullness, mild discomfort, or hearing loss, but it does not usually cause redness, swelling, purulent discharge, or pain with pinna/tragus manipulation. This rules out excessive cerumen as the cause.

A. Since the reading is within the normal range, the client does not require immediate interventions such as supplemental oxygen or advanced respiratory support. Routine monitoring and continued assessment are sufficient unless there are other clinical signs of respiratory compromise, such as increased work of breathing, cyanosis, or altered mental status.

B. An oxygen saturation below 95% is generally considered abnormal in most healthy adults, as it may indicate hypoxemia or impaired gas exchange. A reading of 97% is normal and does not indicate the presence of hypoxia or inadequate oxygen delivery.

C. A SpO₂ of 97% confirms that hemoglobin in the client’s blood is adequately carrying oxygen. This is reassuring and suggests that the client’s respiratory and circulatory systems are functioning appropriately at the time of assessment.

D. Pulse oximetry readings can sometimes be affected by factors such as nail polish, poor perfusion, movement, or cold extremities. While these factors can cause inaccurate readings, the scenario does not provide any evidence suggesting inaccuracy. Therefore, it is reasonable to interpret this reading as accurate unless there are other signs or symptoms that would prompt verification.

E. Clients with chronic lung diseases such as chronic obstructive pulmonary disease (COPD) may have baseline oxygen saturations lower than 95%. However, a reading of 97% does not indicate the presence or absence of chronic lung disease. Without additional history or clinical findings, it is not possible to infer chronic lung conditions from a single normal reading.