A nurse is caring for a client who has a tracheostomy tube and requires suctioning.

Which of the following actions should the nurse take to prevent hypoxia during the procedure?

Rales

Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.

Incorrect options:

A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.

B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.

D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.

Respiratory depression

Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.

Incorrect options:

A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.

B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.

C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.