A patient’s oxygen saturation falls to 82% while the patient is repeatedly moving the hand with the probe. The patient is pink and speaking comfortably. What should the nurse do first?
Correct answer: A. Support the hand, check probe placement and repeat the reading
- A. Support the hand, check probe placement and repeat the reading
- B. Immediately document severe hypoxaemia without further assessment
- C. Increase oxygen to a high flow rate without checking the reading
- D. Remove the probe permanently because movement makes it unreliable
Explanation
Movement can create motion artefact and produce an unreliable pulse oximeter reading. Stabilising the hand, checking the probe and confirming the waveform helps distinguish artefact from true hypoxaemia before further action.
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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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