The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

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Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa (Option B). Oral care is provided to decrease bacteria and contaminants as well as promote comfort (Option D). Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis (Option E). (Options A and C) Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication. Educational objective: Recently extubated clients are immediately placed on humidified oxygen and monitored for aspiration, airway obstruction, and respiratory distress. Clients should remain NPO until swallowing function has been evaluated. In addition, clients should be given routine oral care as well as instructions on coughing, deep breathing, and use of incentive spirometry.

The Intensive Care Nurse Is Caring for a Client Who