The nurse assists the client to perform routine hygiene. The client's oxygen saturation (SaO2) is 90%. Which is the best intervention for the nurse to implement?
1. Limit self-care measures.
2. Increase self-care gradually.
3. Apply oxygen by facemask.
4. Reschedule routine hygiene.
1
1. The nurse limits the client's performance of self-care until the SaO2 increases be-cause an SaO2 less than 95% is too low to meet tissue oxygen demands. Client movements increase oxygen tissue demands and force the client's system to use anaerobic metabolism, thereby increasing the risk of acidosis.
2. Once the SaO2 stabilizes consistently, the nurse gradually increases client self-care.
3. The nurse reduces the client's tissue oxygen demands by instructing the client to lie quietly, breathe, and relax while the nurse monitors the SaO2 briefly to observe an improvement to 95%. If the client does not improve quickly, supplemental oxygen can be indicated.
4. Rescheduling the hygiene is premature.
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