Asked by adiba yeakub on May 25, 2024
Verified
The nurse enters the client's room and before he can take vital signs,he hears a piercing,high-pitched sound coming from the client when he breathes.The nurse's initial next best action is to:
A) Document the finding and continue with the assessment
B) Ask the client to take several deep breaths over the next 24 hours
C) Give the client extra fluids to loosen the secretions of mucus
D) Assess the client's airway patency
Airway Patency
The state of the airway being open and unobstructed to ensure adequate air flow.
Deep Breaths
A breathing technique involving slow, deliberate inhalation and exhalation, used to reduce stress and promote relaxation.
Secretions
Substances produced and released by cells or glands in the body, such as saliva, mucus, or sweat.
- Acquire knowledge on how to assess postoperative vital signs and identify suitable nursing measures.
Verified Answer
LW
Lauren WilsonMay 31, 2024
Final Answer :
D
Explanation :
These sounds are known as stridor and indicate that the client is in respiratory distress or has an obstructed airway.The nurse's initial action is to assess the patency of the airway.Coughing would help if the problem involved rhonchi.Stridor requires an immediate assessment of the client's airway patency.
Learning Objectives
- Acquire knowledge on how to assess postoperative vital signs and identify suitable nursing measures.