The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%

Question

What is the best action of the nurse?
a.
Insert an oral airway and administer oxygen.
b.
Call for anesthesia to immediately reintubate the patient.
c.
Remove the pillow from behind the patient's head.
d.
Elevate the head of the patient's bed.

Answer 1

ANS: A
The snoring sounds made by the patient and low oximetry levels indicate that the patient's airway is partially occluded due to the effects of anesthesia and pain medication. An oral airway should be inserted and oxygen administered to maintain the airway and oxygenation. Reintubation should be performed if the oral airway alone does not maintain the airway and improve oxygenation. Removing the pillow from the head of the patient's bed or elevating the head of the patient's bed will not be sufficient to open the patient's airway.