The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first?

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A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. (Option B) Hyper-oxygenating would not increase ventilation if the tube is not in proper position or if the client has a pneumothorax. (Option C) The first step is to confirm tube placement. Manually ventilating through a displaced tube would produce no better results than use of the ventilator. (Option D) Mucus plugs are a common cause of decreased oxygen saturation in the intubated client. There are, however, specific symptoms associated with this problem, including secretions backing up in the tube and high-pressure ventilator alarms. Although this client may still need suctioning even if these symptoms are not present, auscultating lung sounds is necessary to confirm tube placement before suctioning. Suctioning via a displaced tube could cause additional damage to the client's airway. Educational objective: Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention.

The Nurse Is Caring for an Intubated Client Whose Oxygen