Q5. A patient post‑seizure has SpO₂ 88% on room air. What is the most appropriate nursing action?

Question

BlackTom AI · Accepted Answer

An SpO₂ of 88% indicates clinically significant hypoxemia that requires immediate intervention to restore adequate oxygenation; therefore the priority is to support breathing and deliver high‑concentration oxygen.

Relevant knowledge points:
- ABCs (Airway, Breathing, Circulation) prioritize interventions: airway and oxygenation come before documentation or non‑urgent measures.
- Target SpO₂ for most adults is ≥94% (in COPD patients targets may be lower, e.g., 88–92%); post‑seizure patients are at risk of hypoxia and should receive supplemental oxygen.
- A non‑rebreather mask (NRB) at high flow (typically 10–15 L/min, commonly set at 15 L/min) provides a high FiO₂ (~60–90%) and is appropriate for immediate high‑concentration oxygen delivery in hypoxemia.

Step‑by‑step reasoning:
1. Recognize the SpO₂ reading: 88% = moderate hypoxemia requiring urgent correction.
2. Apply ABCs: ensure airway patency and begin high‑flow oxygen to improve oxygenation quickly.
3. Choose the appropriate device: an NRB at 15 L/min delivers the highest non‑invasive FiO₂ immediately available in many clinical settings.
4. After applying NRB, reassess respiratory rate, work of breathing, and SpO₂; escalate (bag‑valve ventilation, advanced airway) if oxygenation does not improve.

Why the correct answer is correct:
Applying oxygen via a non‑rebreather mask at 15 L/min directly addresses the immediate life‑threat (hypoxemia), is rapid to implement, and provides high FiO₂ to restore SpO₂ toward normal. This aligns with airway/breathing priorities after a seizure.

Why other options are incorrect:
- Restraining patient hands to prevent injury: Contraindicated unless absolutely necessary and unsafe; restraints do not treat hypoxia and can worsen agitation or injury.
- Insert a nasopharyngeal airway: May be appropriate if airway is obstructed and patient has depressed consciousness, but it does not deliver supplemental oxygen and is not the first action for hypoxemia unless airway obstruction is primary.
- Document seizure and continue monitoring: Documentation is important but not an immediate priority over treating low SpO₂.

Conclusion: The most appropriate nursing action is to apply oxygen via a non‑rebreather mask at 15 L/min, which matches the provided correct answer.

Q5. A patient post‑seizure has SpO₂ 88% on room air. What is the most appropriate nursing action? 单项选择题

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