The nurse is caring for a homeless client brought to the emergency department with possible hypothermia. The nurse places the pulse oximeter probe on the client's finger and gets a reading of 38%
The client's respiratory rate is 22 breaths per minute, breath sounds are clear and equal, color is pale pink, and the client denies any history of respiratory distress. Which is the priority action by the nurse?
1. Apply oxygen
2. Call the health care provider
3. Call the rapid response team
4. Move the pulse oximetry sensor to the ear or nose
Correct Answer: 4
The nurse should move the sensor to a central area, such as the ear or nose, because the client who was exposed to the cold most likely has diminished peripheral perfusion, which could give a falsely low oximetry reading. The client's assessment does not indicate respiratory distress, so application of oxygen or calling the health care provider would not be warranted at this time. The rapid response team usually is not required in the emergency department because there are health care providers available.
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