The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient's temperature is 100.1° F (37.8° C).
d. The patient complains of level 8 (0 to 10 scale) pain.
ANS: A
Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.
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