The nurse hears the patient's stridor from the hallway and notes that the patient's oxygen saturation has decreased to 92%. Which nursing intervention does the nurse implement first?

Question

a. Adjust the patient's position.
b. Suction the oropharynx.
c. Insert an artificial airway.
d. Review the last arterial blood gases (ABGs).

Answer 1

A
The nurse implements a noninvasive intervention to enhance the patient's airway before institut-ing an invasive measure because, although the patient's airway is impaired, he or she continues to oxygenate fairly well but is working very hard to do so. By quickly adjusting the patient's po-sition to maximize gas exchange and chest expansion, the nurse intervenes and gains additional valuable data for planning additional nursing care. Suctioning is contraindicated for stridor be-cause it can aggravate stridor to laryngospasm. The nurse avoids inserting an airway because the patient has stridor, an airway impairment in the trachea. If the patient needs an artificial airway, the nurse needs to provide an endotracheal tube or tracheostomy to restore his or her airway be-cause the obstruction is beyond the reach of an oral airway. The nurse avoids ABGs because valuable data are already available for patient assessment; ABGs are not necessary yet.