A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler's position.
d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.
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