HESI Registered Nurse EXIT Practice Exam

What finding after endotracheal tube insertion would require immediate action by the nurse?

1. Breath sounds can be heard bilaterally

2. Pulse oximetry of 88

3. Client is unable to speak

4. Mist is visible in the T-Piece

The correct answer is: Pulse oximetry of 88

After endotracheal tube insertion, a pulse oximetry reading of 88% indicates that the patient's oxygen saturation level is significantly below the normal range of 95-100%. This low reading suggests that the patient may be experiencing hypoxemia, which can quickly lead to tissue hypoxia and other serious complications if not addressed immediately. In the context of airway management, hypoxemia can occur for several reasons, including improper placement of the endotracheal tube (e.g., in the esophagus instead of the trachea), inadequate ventilation, or a significant respiratory issue. Therefore, a pulse oximetry reading of 88% is a critical finding that necessitates urgent intervention, which may include confirming correct tube placement, providing additional oxygen, or initiating manual ventilation. Breath sounds being present bilaterally is a reassuring sign and indicates that air is reaching both lungs. While the client being unable to speak is typical after intubation and therefore not an immediate concern, it does not imply a pathology requiring immediate action. Likewise, mist in the T-Piece is often a normal finding indicating humidity and moisture, suggesting appropriate humidification in the airway management process, and does not require urgent intervention.