A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

A. Check the client's medical records to see which medications were recently administered:
While reviewing medications is important for understanding potential causes of hypoxia, it is not the immediate priority when a client’s oxygen saturation is low. Immediate assessment and intervention to improve oxygenation come first.

B. Notify the charge nurse of the client's condition: Notifying the charge nurse is important but should follow an initial assessment and attempt to address the problem. Immediate client reassessment takes precedence to determine the current status and possible interventions.

C. Review the client's most recent SaO2 level in the medical record: Checking prior oxygen saturation levels can provide context but does not directly address the acute finding of 88% saturation, which requires prompt evaluation and action.

D. Recheck the client's SaO2 level after having the client cough and clear their throat: This action directly addresses a common cause of transient hypoxia such as airway obstruction from secretions. Reassessment after clearing the airway is the priority to determine if oxygenation improves before escalating interventions.

Target 1: Paralytic ileus

• The client is 6 hours postoperative with hypoactive bowel sounds and no mention of flatus or stool. The use of IV opioids (morphine) increases the risk for reduced gastrointestinal motility. Paralytic ileus is common after abdominal surgery and with opioid use.

Target 2: Atelectasis

• The client has shallow bilateral breath sounds postoperatively, which indicates a risk for atelectasis, a common complication due to decreased mobility, pain limiting deep breathing, and effects of anesthesia.

Rationale for Incorrect Choices:

• Urinary tract infection: The client voided 350 mL of clear yellow urine after catheter removal with no signs of infection.
• Delayed wound healing: No signs of infection or poor wound healing; the dressing is dry and intact.
• Deep vein thrombosis: Though a risk postoperatively, the client is wearing SCDs and has even pedal pulses with no edema, lowering immediate concern.