The nurse auscultates the following lung sound in a client with a respiratory disorder. What is the nurse's best action? (Click the media button to hear the audio clip.)
a. Have the client use an incentive spirome-ter.
b. Have the client cough and deep breathe.
c. Suction the client after auscultating the lower lobes of the lungs.
d. Call for the Rapid Response Team.
D
The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and he-ralds impending airway occlusion. The client's airway is in jeopardy and immediate intervention is necessary. Using the spirometer or coughing and deep breathing will not help the client in this situation. The nurse needs to call the Rapid Response Team.
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