While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowler's position.
d. Ask the client to perform deep-breathing exercises.
ANS: A
Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler's position and asking the client to perform breathing exercises may temporarily improve the client's comfort, these actions will not decrease the underlying problem or improve airway patency.
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