Question

A nurse is assessing a client while suctioning a clients trach tube. Which of the following findigs should indicate to the nurse the client is experiencing hypoxia?

a) The client's respiratory rate is 28 breaths per minute.
(b) The client's oxygen saturation is 88%.
(c) The client's heart rate is 120 beats per minute.
(d) The client is using accessory muscles to breathe.

Answer 1

The client's low oxygen saturation level of 88% indicates hypoxia, as a normal healthy reading typically falls at 95% or above. In the scenario provided, this is the most direct sign of hypoxia that the nurse should consider during the suctioning of a client's trach tube.

Step-by-step explanation:

When assessing a client during suctioning of a tracheostomy tube, several findings could indicate the client is experiencing hypoxia, a condition where there is insufficient oxygen reaching the tissues. The nurse should look for clinical signs such as:

• An elevated respiratory rate above the normal 12-15 breaths per minute.
• A low oxygen saturation level, such as 88%, measured by a pulse oximeter.
• An increased heart rate, like 120 beats per minute, as the body attempts to transport more oxygen through the blood.
• Use of accessory muscles to breathe, which indicates difficulty in breathing and the body's attempt to maximize air intake.

Of the choices provided, (b) The client's oxygen saturation is 88% is a direct indication of hypoxia, as a typical healthy reading is usually 95% or above. Therefore, the client's low oxygen saturation level should alert the nurse to the presence of hypoxia.