A nurse is planning to administer an intermittent enteral feeding through a client's percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions should the nurse take?

Post-anesthesia care unit (PACU) management focuses on maintaining airway patency, adequate ventilation, and oxygenation following sedation or anesthesia. Clients are at increased risk for hypoventilation, airway obstruction, and atelectasis due to residual anesthetic effects. Oxygen therapy must be titrated based on oxygen saturation trends and clinical status. Nurses continuously assess respiratory function and escalate oxygen delivery methods when needed to maintain adequate oxygenation.

Rationale:
A. Adding a humidifier to the oxygen device is appropriate because higher oxygen flow rates can dry mucous membranes, especially when oxygen is increased to 4–5 L/min. Humidification helps maintain airway moisture, improves secretion clearance, and enhances patient comfort during oxygen therapy. This is particularly important in postoperative clients receiving supplemental oxygen.

B. Examining the client’s nail beds is appropriate because peripheral perfusion and oxygenation status can be indirectly assessed through nail bed color and capillary refill. Although pulse oximetry is primary, physical assessment provides additional information about oxygen delivery to tissues. Pale or cyanotic nail beds may indicate inadequate oxygenation requiring further intervention.

C. Placing the client in the supine position is not appropriate because it can decrease lung expansion and increase the risk of airway obstruction, especially in a sedated postoperative client. The semi-Fowler’s position is preferred as it promotes lung expansion and improves oxygenation. Supine positioning may worsen hypoventilation in PACU patients.

D. Encouraging deep breathing exercises is appropriate because it promotes alveolar expansion and helps prevent atelectasis following sedation or anesthesia. Deep breathing improves oxygen exchange and supports removal of anesthetic gases. This intervention is essential in preventing postoperative pulmonary complications.

E. Preparing to administer oxygen via Venturi face mask is inappropriate because a Venturi mask is typically used when a very precise, high concentration of oxygen is required, often for clients with COPD. For a client in the PACU experiencing mild postoperative desaturation, a nasal cannula or a simple face mask is usually sufficient unless the saturation continues to drop despite being at the maximum flow rate for those devices.

A stapedectomy is a surgical procedure performed to improve conductive hearing loss in clients with otosclerosis by replacing or bypassing the immobilized stapes bone. Postoperative care focuses on monitoring for complications such as inner ear trauma, facial nerve injury, infection, and vestibular dysfunction. Because the surgery involves delicate structures of the middle and inner ear, neurologic and sensory changes must be closely evaluated. Early identification of abnormal findings is essential to prevent permanent deficits.

Rationale:
A. Lung assessment showing clear bilateral breath sounds does not require further action because it is an expected and normal finding. There is no indication of respiratory compromise or postoperative pulmonary complication. Normal lung sounds suggest adequate ventilation and oxygenation status.

B. Pain rating of 5 out of 10 is expected after ear surgery and is not necessarily abnormal if it is controlled with prescribed analgesics. Mild to moderate postoperative pain is common following a stapedectomy due to tissue manipulation. Pain alone, without other concerning signs, does not require urgent intervention.

C. Diminished hearing following surgery requires further action because although temporary changes may occur, worsening or unexpected hearing loss may indicate inner ear injury or prosthesis displacement. Postoperative hearing should be monitored closely to differentiate expected transient changes from complications. Significant or progressive hearing loss warrants immediate evaluation.

D. Facial nerve assessment showing facial droop requires urgent attention because it may indicate facial nerve injury during surgery. The facial nerve runs close to the middle ear structures and can be affected during a stapedectomy. Facial asymmetry is an abnormal neurologic finding that requires prompt notification of the provider.

E. Pupils that are equal, round, and reactive to light are normal postoperative neurological findings and do not require intervention. Stable pupil response indicates intact cranial nerve function and adequate neurological status. No further action is needed for this finding.

F. Vertigo requires further evaluation because it may indicate inner ear disturbance or vestibular involvement following stapedectomy. Mild dizziness can be expected postoperatively, but significant vertigo accompanied by nausea may suggest labyrinthine irritation or complication. This finding should be monitored and reported if persistent or worsening.