The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhala-tion. What is the nurse's best action?
a. Perform peak expiratory flow readings.
b. Assess for a midline trachea.
c. Administer oxygen and a rescue inhaler.
d. Call a code.
C
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway nar-rowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also sup-ports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.
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