A nurse is caring for a client who has an acute respiratory illness. For which manifestations of an airway obstruction should the nurse monitor? (Select all that apply.) A. Inspiratory stridor B. Nausea C. Retractions D. Muscle tremors E. Cyanosis
Answer (2)
The key manifestations of airway obstruction to monitor are inspiratory stridor, retractions, and cyanosis. Nausea and muscle tremors are not indicators of airway obstruction. These symptoms help the nurse assess the severity of the client's respiratory status and provide timely interventions.
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When a nurse is caring for a client with an acute respiratory illness, monitoring for signs of airway obstruction is crucial. Airway obstruction can compromise breathing and lead to serious complications. The following manifestations are indicators of potential airway obstruction:
A. Inspiratory stridor – This is a high-pitched, wheezing sound caused by disrupted airflow. It typically occurs during the inhalation phase and is a significant sign of upper airway obstruction.
B. Nausea – While nausea is a symptom that can occur for various reasons, it is not a direct indicator of airway obstruction and is therefore not relevant in this context.
C. Retractions – This occurs when the muscles between the ribs pull inward. Retractions are a sign that extra effort is being used to breathe and can indicate an obstruction in the airway.
D. Muscle tremors – Muscle tremors are not typically related to airway obstruction. They might occur due to other conditions or medication side effects, but they do not provide direct information about the airway status.
E. Cyanosis – This refers to a bluish coloration of the skin and mucous membranes resulting from a lack of oxygen in the blood. Cyanosis is a critical sign of severe airway obstruction and indicates inadequate oxygenation.
Therefore, options A (Inspiratory stridor), C (Retractions), and E (Cyanosis) are manifestations of an airway obstruction that the nurse should monitor in a client with an acute respiratory illness.
