A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform?
a. Prepare to intubate.
b. Assess the patient's condition.
c. Turn off the alarm and reapply the oximeter sensor.
d. Increase O2 level to 4L/NC.
B
The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the Spo2 . The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.
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