The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clear-ing secretions
Which is the nurse's priority action? a. Place the client in a high Fowler's posi-tion.
b. Prepare the client for elective intubation.
c. Administer oxygen via a nasal cannula.
d. Auscultate for breath sounds.
B
Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indi-cations for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.
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