A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
a. Administer prescribed salmeterol (Serevent) inhaler.
b. Assess the client for a tracheal deviation.
c. Administer oxygen to keep saturations greater than 94%.
d. Perform peak expiratory flow readings.
e. Administer prescribed albuterol (Proventil) inhaler.
ANS: C, E
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.
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