Question

After the NAP performs routine vital signs on the patient, the NAP reports to the nurse that the patient is restless, and it sounds like the patient is gurgling. Vital sign readings indicate a pulse of 72, respiratory rate of 20 breaths per minute, and a pulse oximetry of 89%. What is the most appropriate action at this time?

A) Document the normal findings.
B) Consult with the physician regarding need for a bronchodilator.
C) Suction the patient's airway.
D) Have the patient take a deep breath and reassess pulse oximetry.

Answer 1

The patient's low oxygen saturation and gurgling sounds may indicate airway obstruction, making suctioning the airway the most appropriate action to improve oxygenation and prevent further deterioration.

Step-by-step explanation:

When a patient is restless and exhibits signs of respiratory distress, such as gurgling and a reduced pulse oximetry reading of 89%, immediate action is essential to ensure adequate oxygenation and prevent further deterioration. Normal vital signs for adults typically include a heart rate of 60-100 beats per minute, a respiratory rate of 12-18 breaths per minute, and a pulse oximetry over 95%. Given that the patient's oxygen saturation is below normal and is accompanied by abnormal respiration sounds, the situation suggests potential airway obstruction or fluid in the airway, requiring rapid intervention.

Given these clinical indicators, the most appropriate action in this scenario would be suctioning the patient's airway (Option C), as it can help to remove secretions obstructing the airway and improve oxygenation. Consultation with a nurse or physician regarding further assessment or the need for additional interventions, such as administration of a bronchodilator or supplemental oxygen, should follow immediately after airway clearance.