While assessing Ricardo Mendoza, a nurse notes an oxygen saturation level of 85% on 2 L/min via nasal cannula and a respiratory rate of 36. Which nursing action is indicated? Increase the oxygen to 4 L/min via nasal cannula. No action is needed. Tell the patient to cough and deep breathe. Apply oxygen via face mask at 15 L/min.
In this situation, the most appropriate nursing action is to apply oxygen via face mask at 15 L/min.
Here’s the reasoning behind this choice:
Oxygen Saturation: An oxygen saturation level of 85% is considered low and indicates hypoxemia, which requires prompt intervention.
Current Oxygen Delivery: The patient is currently on 2 L/min via nasal cannula, which may not be sufficient to raise their oxygen saturation to an acceptable level.
Increased Oxygen Demand: With a respiratory rate of 36 breaths per minute, the patient is likely experiencing respiratory distress, and their oxygen needs may be higher than what a nasal cannula can provide.
Face Mask Benefits: A face mask can deliver a higher concentration of oxygen (up to 100% if properly fitted and used), which is necessary for a patient with significantly low oxygen saturation.
Safety and Monitoring: After applying the face mask, the nurse should closely monitor the patient’s oxygen saturation and respiratory status to assess the effectiveness of the intervention.
Therefore, applying oxygen via a face mask at 15 L/min is the most appropriate and immediate action to improve the patient’s oxygenation status.