The nurse enters the client's room and before taking vital signs, the nurse hears a piercing, high-pitched sound coming from the client when breathing. Which best action should the nurse take initially?

Question

Quizplus · Accepted Answer

The high-pitched sound indicates a potential airway obstruction or narrowing, which is a critical situation. The nurse's first action should be to assess the client's airway patency to ensure the client is getting enough air.

The Nurse Enters the Client's Room and Before Taking Vital