A nurse is caring for a client who has heart failure and respiratory arrest. What should be the nurse’s first action?

Choice B rationale:

Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:

Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.

Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.

Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.

Blood or secretions in the airway: These can obstruct the airway and cause stridor.

It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:

Oxygen therapy: This can help to improve the patient's breathing.

Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.

Establishing an open airway is the most crucial and immediate action in any respiratory arrest situation, including when a client has heart failure. Here's a detailed explanation: 1. Airway patency is paramount for survival: Oxygen, the essential element for life, cannot reach the lungs and bloodstream without a clear and unobstructed airway. Brain cells are extremely sensitive to oxygen deprivation and start to die within minutes without it, leading to irreversible brain damage or death. 2. Respiratory arrest in heart failure: Heart failure often leads to fluid buildup in the lungs (pulmonary edema), which can significantly impair breathing. Respiratory arrest can occur due to: Excessive fluid accumulation in the lungs. Weakening of respiratory muscles due to fatigue or heart failure itself. Arrhythmias or heart blocks affecting heart's ability to pump effectively. 3. Steps to establish an open airway: Head tilt-chin lift maneuver: Gently tilt the head back and lift the chin to open the airway. Jaw thrust maneuver: If a neck injury is suspected, use the jaw thrust maneuver to avoid further injury. Removal of any visible obstructions: Clear any visible foreign objects or fluids from the mouth or throat. Use of airway adjuncts: Consider using oral or nasal airways to maintain airway patency, especially if the patient is unconscious.

4. Rationale for other choices:

A. Auscultating for breath sounds: While important for assessment, it does not address the immediate need to establish airflow.

C. Establishing IV access: IV access is necessary for medications and fluids, but airway takes priority in respiratory arrest.

D. Feeling for a carotid pulse: Checking for a pulse is essential, but only after ensuring an open airway and attempting to restore breathing.

5. Importance of prioritizing airway: Establishing an open airway allows for potential rescue breaths and ventilation, which can help restore oxygen levels and prevent further deterioration. Even if a pulse is present, without a clear airway, oxygen cannot reach the vital organs, leading to organ failure and death.