Physiological Integrity Q 16
The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
A. Notify the physician
B. Recheck the O2 saturation level in 15 minutes
C. Apply oxygen by mask
D. Assess the pulse
Correct Answer: C. Apply oxygen by mask
Remember the ABCs (airway, breathing, circulation) when answering this question. Administer oxygen first to increase the O2 saturation level. Provide humidified oxygen as ordered. Administering humidified oxygen prevents drying out the airways, decreases convective moisture losses, and improves compliance.
Option A: Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function. Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation.
Option B: The normal oxygen saturation for a child is 92%–100%. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%. Pulse oximetry reading of 87% below may indicate the need for oxygen administration while a pulse oximetry reading of 92% or higher may require oxygen titration.
Option D: Before assessing the pulse, oxygen should be applied to increase the oxygen saturation. Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function.