B.K. eventually falls asleep and seems to be sleeping peacefully. several hours later, you hear an alarmon her pulse oximeter and enter her room to investigate. You find B.K. moaning softly; her oximeterreads 87%
What will you do next?
• Check to ensure that the oxygen tubing is still connected and properly inserted in her nares.
• Sit her upright in bed with the HOB elevated.
• Auscultate lung sounds for any changes.
• Inquire about B.K.'s pain level; determine her level of orientation.
• Try pulmonary toilet: C&DB, use the IS (to clear any atelectasis in the lung bases and promote
diffusion of oxygen). If these interventions do not increase Spo2 to over 92%, titrate by increasing
the oxygen to 3 to 4 L/min if ordered. If no order, increase then call the rapid response team and
her physician, and stay with her.
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A teenage female client, when being assessed by the nurse for a minor injury, is curious to know what can be identified as the greatest challenges she will face in early adulthood. What should the nurse's response include?
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