A medical ward patient suddenly becomes breathless and restless. The oxygen saturation is 86% on room air, compared with 97% two hours earlier. What should the nurse do first?
Correct answer: B. Apply oxygen according to protocol and assess the patient's breathing
- A. Document the value and repeat it at the end of the shift
- B. Apply oxygen according to protocol and assess the patient's breathing
- C. Offer oral fluids and ask the patient to rest in bed
- D. Measure the temperature before taking any further action
Explanation
The sudden fall in oxygen saturation with breathlessness indicates impaired breathing, so airway and breathing take priority. The nurse should position the patient, apply oxygen according to local protocol, assess the airway and breathing, and seek urgent help.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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