A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.)
a. Assess for airway obstruction.
b. Initiate oxygen therapy.
c. Assess vital signs.
d. Elevate the client's head.
ANS: A
Stridor is the sound heard, and it indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen, assessing vital signs, and elevating the client's head will not help until the client's airways are open.
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