Question

A nurse is assessing a client's vital signs. The oxygen saturation is 85%. What intervention should the nurse perform first?

A) Notify the healthcare provider immediately
B) Administer oxygen therapy to the client
C) Recheck the pulse oximeter reading
D) Position the client upright to facilitate breathing

Answer 1

The first step the nurse should take when a client has an oxygen saturation of 85% is to recheck the pulse oximeter reading to confirm its accuracy. Following this, the nurse should administer oxygen therapy if the low reading persists and then proceed with further interventions as required.

Step-by-step explanation:

A nurse who assesses a client with an oxygen saturation of 85% is encountering a situation indicative of hypoxemia, or low blood oxygen. Considering the normal range for oxygen saturation is between 95-100%, an intervention is required. The first and immediate intervention should be to recheck the pulse oximeter reading to ensure that the reading is accurate. This can involve checking that the device is functioning correctly and confirming that there is correct placement on the patient's finger. If after rechecking the reading remains low, the nurse should then administer oxygen therapy to the client, which is an immediate intervention to increase the client's oxygen levels. Notifying the healthcare provider and positioning the client to facilitate breathing should follow these initial steps, assuming the patient does not show signs of severe distress requiring immediate escalation of care.