The endotracheal tube of a postoperative client transferred to the post-anesthesia care unit (PACU) was removed for five minutes. The client develops acute inspiratory stridor with sternal retractions
Which of these actions should the nurse take immediately? a. Reinsert the endotracheal tube.
b. Reassure the client.
c. Prepare to initiate cardiopulmonary resuscitation.
d. Start oxygen via mask.
C
When a client experiences acute inspiratory stridor with sternal retractions, it is an indication of respiratory distress. The nurse cannot replace the endotracheal tube and must be prepared to initiate cardiopulmonary resuscitation (CPR). The surgeon or anesthesiologist should be notified immediately.
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