What immediate action should a nurse take for a patient with SpO₂ of 88%?

• A. Apply oxygen via nasal cannula per unit protocol and reassess
• B. Notify physician to intubate
• C. Place patient in Trendelenburg position
• D. Document and continue observation

Answer: (A)

SpO2 of 88% shows hypoxemia that needs immediate correction to improve oxygen delivery to tissues. The best first step is to administer supplemental oxygen using the unit’s protocol, typically starting with a nasal cannula at the prescribed flow, then reassessing the SpO2 and the patient’s clinical status after a short interval. Providing oxygen promptly addresses the low saturation and can quickly raise arterial oxygen levels.

If the patient’s saturation improves, continue to monitor and adjust per protocol. If there is no improvement or signs of worsening respiratory distress, escalate as indicated by the protocol (for example, higher FiO2 or a more advanced airway support). Avoid delaying intervention by waiting or choosing repositioning that doesn’t improve oxygenation, and avoid routing to intubation as the immediate step unless airway failure or severe deterioration is present.