The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 seconds. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action will the nurse take?

Intervention: Validate that informed consent has been given by the client.

Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.

Assessment: The trachea is shifted away from the midline of the neck.

Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.

Choice B: Pulse oximetry is 93% on 2 L of oxygen.

Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.

Choice C: The client rates pain as 8/10 at the site of the procedure.

Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.

Choice D: Request an order for pain medication.

Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.

Choice E: Measure oxygen saturation before and after a 12-minute walk.

Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.

Choice F: Explain the procedure in detail to the client and the family.

Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.

Choice G: Assist the client to the bathroom.

Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.

Choice H: Discuss all possible complications with the client.

Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.

Choice I: A small amount of drainage from the site is noted.

Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.

Choice A Reason:

Assess the client’s oxygen saturation and, if normal, turn off the oxygen. This option is not ideal because turning off the oxygen completely can lead to a rapid drop in oxygen saturation levels, especially in patients who require continuous oxygen therapy. Monitoring oxygen saturation is crucial, but turning off the oxygen is not recommended unless specifically advised by a healthcare provider. Normal oxygen saturation levels typically range from 95% to 100%1. If the levels drop below 90%, it can lead to hypoxemia, which can cause serious complications.

Choice B Reason:

Have the client lift the mask off the face when taking bites of food. This option is also not ideal because it can be cumbersome for the client and may lead to inconsistent oxygen delivery. The Venturi mask is designed to provide a precise concentration of oxygen, and lifting it off repeatedly can disrupt this consistency. Additionally, it can be uncomfortable and impractical for the client to manage the mask while eating.

Choice C Reason:

Turn the oxygen off while the client eats the meal and then restart it. This option is not recommended for similar reasons as Choice A. Turning off the oxygen can lead to a significant drop in oxygen saturation levels, which can be dangerous for the client. Continuous oxygen therapy is essential for maintaining adequate oxygen levels in patients who require it. Interrupting this therapy, even temporarily, can have adverse effects on the client’s health.

Choice D Reason:

Determine if the client can switch to a nasal cannula during the meal. This is the best option because a nasal cannula allows the client to receive continuous oxygen while eating. The nasal cannula is less obtrusive and more comfortable for the client, enabling them to eat without significant interruption to their oxygen therapy. Nasal cannulas are commonly used for patients who need supplemental oxygen but also need to perform activities such as eating and talking. This approach ensures that the client maintains adequate oxygen levels while having their meal.