Which finding requires immediate follow-up by the nurse? (Choose the most urgent)

• A. Pleuritic type chest pain of 7 on a 0 to 10 scale
• B. Reduced skin turgor
• C. Oxygen saturation of 78%
• D. Pattern of chest movement

Answer: (C)

Recognize that severe hypoxemia demands immediate action. An oxygen saturation reading of 78% means the body's tissues aren’t getting enough oxygen right now, which can rapidly lead to organ dysfunction. In practice, any SpO2 below 90% is a red flag, and values as low as 78% are a medical emergency. The nurse should respond right away by ensuring the airway is open, delivering oxygen promptly, and mobilizing additional help while continuously monitoring the patient’s breathing and circulation. Assess for and address potential causes of the drop, such as airway obstruction, respiratory failure, pneumothorax, or severe infection, and be prepared for advanced interventions if the patient does not improve.

The other findings, while important to monitor, do not indicate an immediate life-threatening hypoxemic event: pleuritic chest pain can be significant and warrants further evaluation, dehydration signs like reduced skin turgor indicate fluid loss issues to address, and abnormal chest movement can signal respiratory effort problems but does not override the urgency of correcting critically low oxygen saturation.