The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
a) Sudden restlessness
b) Copious mucous secretions
c) Harsh cough
d) Rhonchi in lung fields
Answer: a) Sudden restlessness
Explanation:
Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions. pg.517
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