NCLEX Examination.
Practice Question # 650.
NCLEX Quiz
Assessing for respiratory distress:
You should assess for signs of respiratory distress as part of your postoperative assessment. Contact the doctor if your findings include the following signs.
The blues
Cyanosis is a major indicator of respiratory distress. Circumoral, nail bed, or sublingual cyanosis indicates an arterial oxygen saturation level of less than 90%. Earlobe cyanosis, usually accompanying chronic obstructive pulmonary disease, may be exacerbated by anesthesia.
Other signs
Also, assess for other signs of respiratory distress, including:
• nasal flaring
• inspiratory or expiratory grunts
• changes in posture to ease breathing
• progressive disorientation.
A little help from your friends
You may use a pulse oximeter to supplement your assessment. Report a saturation level of 90% or less.
