The client with laryngeal trauma who is receiving high-flow oxygen therapy by Venturi mask is now experiencing dyspnea and has sternal retractions. What is the nurse's best first action?
A. Document the observation as the only action.
B. Raise the head of the bed to 90 degrees.
C. Assess bilateral breath sounds.
D. Notify the trauma team.
D
Respiratory status change in a client with laryngeal trauma is a harbinger of an occluded airway. Raising the head of the bed will not modify the problem. The client may need an artificial air-way. Rapid response by the trauma team may permit endotracheal tube placement rather than a tracheotomy.
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