A patient’s pulse oximeter displays 89%, but the patient’s fingers are cold and the waveform is weak. What should the nurse do first?
Correct answer: B. Warm the hand and reposition the sensor before rechecking
- A. Increase the oxygen flow immediately without reassessment
- B. Warm the hand and reposition the sensor before rechecking
- C. Document severe hypoxaemia and leave the patient undisturbed
- D. Place the sensor over a blood pressure cuff for a stronger signal
Explanation
Cold peripheral tissue and a weak signal can cause an inaccurate low saturation reading. The nurse should improve peripheral perfusion, check sensor placement and signal quality, and reassess promptly, while also assessing the patient’s breathing and overall condition.
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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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