The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?
1. Stridor
2. Lung congestion
3. Respiratory rate of 26 breaths/min
4. Occasional pink-tinged sputum
1
Rationale: The nurse reports the presence of stridor to the physician immediately. This is a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. Congestion ("lung congestion") and a respiratory rate of 26 breaths/min ("respiratory rate of 26 breaths/min") are abnormal, but additional data are needed to determine whether these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.
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