A nurse obtains an unexpectedly low oxygen saturation from a patient whose fingers are cold and moving. What should the nurse do first?
Correct answer: C. Warm the hand and repeat the reading
- A. Document the reading as the patient's baseline
- B. Apply oxygen without checking the measurement
- C. Warm the hand and repeat the reading
- D. Ask the patient to take rapid deep breaths
Explanation
The nurse should validate an unexpected finding by correcting possible equipment or patient factors and repeating the measurement. Oxygen should not be started solely because a possibly inaccurate reading is obtained unless the patient's clinical condition also requires it.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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