When a client’s pulse oximeter alarm shows 80% oxygen saturation while on 2 liters per minute via nasal cannula, what should the practical nurse do next?

When a client’s pulse oximeter alarm shows 80% oxygen saturation while on 2 liters per minute via nasal cannula, what should the practical nurse do next?

• A. Call for assistance from the rapid response team
• B. Check that the placement of the pulse oximeter is correct
• C. Increase oxygen flow to 4 liters per minute
• D. Assess the client’s respiratory rate and work of breathing

Answer: (B)

The most important first step is to confirm the reading by ensuring the pulse oximeter is applied correctly. A sensor that isn’t placed properly or isn’t in good contact can produce a falsely low reading, even if the patient’s oxygenation isn’t as bad as it seems. So, check that the probe is on a well-perfused site, secure and snug, with clean, dry skin and no nail polish or artificial nails blocking the sensor. If the placement and contact are correct and the reading remains 80%, then proceed with a full respiratory assessment (rate, depth, work of breathing, lung sounds) and follow your protocol for escalating oxygen or other interventions as needed. If the patient shows signs of distress, escalate care per your facility’s procedures after confirming accuracy.

The most important first step is to confirm the reading by ensuring the pulse oximeter is applied correctly. A sensor that isn’t placed properly or isn’t in good contact can produce a falsely low reading, even if the patient’s oxygenation isn’t as bad as it seems. So, check that the probe is on a well-perfused site, secure and snug, with clean, dry skin and no nail polish or artificial nails blocking the sensor. If the placement and contact are correct and the reading remains 80%, then proceed with a full respiratory assessment (rate, depth, work of breathing, lung sounds) and follow your protocol for escalating oxygen or other interventions as needed. If the patient shows signs of distress, escalate care per your facility’s procedures after confirming accuracy.