The nurse suctions the client's endotracheal tube and the client becomes hypoxic. Which is the priority nursing intervention to increase client oxygenation?
1. Assess breath sounds
2. Discontinue suctioning.
3. Instruct client to cough.
4. Ventilate client manually.
4
4. If the client becomes hypoxic, the nurse ventilates the client manually with sup-plemental oxygen to increase client oxygenation. The nurse implements measures to oxygenate the client quickly to avoid adverse and potentially life-threatening com-plications, including arrhythmias and cardiopulmonary arrest.
1. The nurse assesses the client after providing supplemental oxygen and before seeking assistance because the hypoxia is most likely transient.
2. The nurse discontinues suctioning to stop the decline in client oxygen saturation; however, this action alone does not increase oxygenation. This nursing intervention halts the declining oxygen saturation but does not inherently increase it.
3. Instructing the client to cough is a reasonable response to hypoxia, especially if the client has pulmonary secretions; however, manual ventilation provides supplemental oxygen in addition to ventilation to increase client oxygenation.
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