A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is $90 \%$ by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action?

Question

Quizplus · Accepted Answer

In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.

A Nurse Is Caring for a Patient Who Is Postoperative 90%90 \%90%

A Nurse Is Caring for a Patient Who Is Postoperative $90 \%$