An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the client's lung sounds.
d. Suction the endotracheal tube.
ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.
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