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
D
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.
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Fill in the blank(s) with the appropriate word(s).