A patient being mechanically ventilated is demonstrating hypoxia, with a pulse oximeter reading of 88%. After ensuring the integrity of the ventilator tubing and assessing the patient, the nurse auscultates adventitious lung sounds
Which action should the nurse take next? 1. Suction the patient.
2. Contact the physician.
3. Turn the patient on the side.
4. Silence the alarm.
1
Rationale 1: When the tubing integrity is intact and the pulse oximeter reading falls to 88% with adventitious breath sounds, the patient needs to be suctioned.
Rationale 2: The physician does not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia.
Rationale 3: Turning the patient on the side has no purpose.
Rationale 4: Silencing the alarm will not resolve the issue.
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