The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
A) Decreased pulse rate, respirations of 20 breaths/minute
B) Increased pulse rate, adventitious breath sounds
C) Increased pulse rate, respirations of 16 breaths/minute
D) Decreased pulse rate, abdominal breathing
B
Feedback:
An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
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