CNOR Operating Room Nursing

Category - Emergencies

Following a surgical procedure, a patient must remain intubated and will be eventually be transferred to the intensive care unit. During transfer to the post-anesthesia care unit, the patient’s oxygen saturation levels begin to drop and they appear cyanotic. What is the appropriate action of the nurse?
  1. Increase oxygen amount administered and check oxygen saturation levels again in five minutes.
  2. Listen to breath sounds to determine if the endotracheal tube is still in place.
  3. Turn the patient to their side and suction their mouth.
  4. Pull the endotracheal tube and begin ventilating by bag and mask.
Explanation
Answer: B-In this situation, the nurse should listen to the patient’s breath sounds to determine if the endotracheal tube is still in place. Breath sounds should be heard on both sides of the patient’s chest if the tube is in the correct position. The tube could have slipped during the patient transfer. The nurse may then consider increasing oxygen or providing manual respirations to the patient to increase oxygenation.
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