The nurse hears the client's stridor from the hallway and notes that the client's oxygen saturation has decreased to 92%. Which nursing intervention does the nurse implement first?
1. Adjust client's position.
2. Suction the oropharynx.
3. Insert an artificial airway.
4. Measure arterial blood gases.
1
1. The nurse implements a noninvasive intervention to enhance the client's airway before instituting an invasive measure because, although the client's airway is im-paired, the client continues to oxygenate fairly well but is working very hard to do so. By quickly adjusting the client's position to maximize gas exchange and chest ex-pansion, the nurse intervenes and gains additional valuable data for planning addi-tional nursing care.
2. Suctioning is contraindicated for stridor because it can aggravate stridor to laryn-gospasm.
3. The nurse avoids inserting an airway because the client has stridor, an airway im-pairment in the trachea. If the client needs an artificial airway, the nurse needs to provide an endotracheal tube or tracheostomy to restore the client's airway because the obstruction is beyond the reach of an oral airway. In addition, the insertion of an airway is likely to make the client gag and increase the risk of airway collapse or as-piration.
4. The nurse avoids arterial blood gases (ABG) because valuable data are already available for client assessment; ABGs are not necessary yet.
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