The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below. What is the nurse's immediate action?

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11ecbb05_cafe_8167_b433_f30a4470db93_MD0009_00 The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option B) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option C) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option D) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective: When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing.

The Nurse Is Caring for a Ventilator-Dependent Client with Neuromuscular