A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used.

Question

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Alzheimer disease is a neurological condition that increases the risk for aspiration and aspiration pneumonia, a common cause of death in clients with swallowing dysfunction. The nurse activates a rapid response because the client is in acute respiratory distress. While waiting for the team, the nurse should implement the following actions in order: Place in high Fowler's position - quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease risk of further aspiration Perform oropharyngeal suctioning - the priority is clearing the airway after the client has been placed in a position that prevents further aspiration Administer 100% oxygen by nonrebreather mask - corrects hypoxemia/hypoxia once the airway has been cleared to allow passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness). Assess lung sounds - determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in place (eg, oxygen) and the client has been stabilized. Notify the primary HCP - to report the situation and assessment data To provide more efficient care, any of these tasks can be delegated to a second RN. Educational objective: While waiting for the rapid response team to respond to an adult client with acute respiratory distress, the nurse implements the following actions: positioning; suctioning to clear the airway, administering high-concentration oxygen; assessing lung sounds; and notifying the HCP.

A Client with Alzheimer Disease Is Found Slumped Over the Lunch