The Nurse Is Providing Care to the Adult Client with Mechanically

The nurse is providing care to the adult client with mechanically ventilated client who has a tracheostomy. The client has a pulse oximetry reading at 85%, heart rate at 113 beats/min, and respiratory rate at 30 breaths/min. The client has become restless and has labored gurgling respirations. The nurse auscultates bilateral crackles and rhonchi. What is the most appropriate nursing action at this time?

A) Call the respiratory therapist for ventilator assessment.
B) Provide sterile endotracheal suctioning.
C) Provide sterile tracheostomy and stoma care.
D) Notify the physician of the client's signs of fluid overload.