The nurse has just received a patient from the surgical area. After 30 minutes in the recovery area, the patient's vital signs are: pulse 92; blood pressure 110/50; respirations 12; and pulse oximeter 86%
What should be the initial nursing response? 1. Call the physician.
2. Ask another nurse for his or her opinion.
3. Stimulate the patient.
4. Place an oral airway in the patient.
3
Rationale 1: The patient's respirations and pulse oximeter are low. Notifying the physician is not the initial nursing response indicated, although it may be necessary if other interventions do not improve ventilation.
Rationale 2: The patient's respirations and pulse oximeter are low. It is not necessary to ask for a second opinion. The nursing assessment is correct and the intervention is standard.
Rationale 3: The patient's respirations and pulse oximeter are low. The nurse's initial response should be to stimulate the patient to see if the pulse oximeter will increase. The patient may require frequent stimulation to improve the oxygen saturation.
Rationale 4: The patient's respirations and pulse oximeter are low, but there is no indication that an oral airway is needed at this time. If the correct initial intervention does not improve oxygenation, an oral airway may be considered.
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Indicate whether the statement is true or false
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