Author Question: An intubated client's oxygen saturation has dropped to 88. What action by the nurse takes priority? ... (Read 160 times)

appyboo · **on:** Jun 25, 2018

An intubated client's oxygen saturation has dropped to 88. What action by the nurse takes priority?

a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the client's lung sounds.
d. Suction the endotracheal tube.

Question 2

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3

yasmina · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

Answer to Question 2

ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.