A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Choice A reason: Pink frothy sputum is a classic sign of pulmonary edema, which can occur as a result of oxygen toxicity. When the alveoli in the lungs fill with fluid, it can lead to this type of sputum. This is a critical indicator that the client is experiencing severe respiratory distress and requires immediate medical attention.

Choice B reason: Substernal discomfort or chest pain is another symptom of oxygen toxicity. This discomfort arises due to the irritation and inflammation of the lung tissues caused by high levels of oxygen. It is essential to monitor and address this symptom promptly to prevent further complications.

Choice C reason: Nail clubbing is typically associated with chronic hypoxia and long-term lung diseases, but it is not an acute indicator of oxygen toxicity. Therefore, it is not relevant in this context.

Choice D reason: Restlessness is a common early sign of hypoxia and can also indicate oxygen toxicity. When the brain does not receive adequate oxygen, it can lead to symptoms such as restlessness, confusion, and agitation. This symptom should be taken seriously and addressed immediately.

Choice E reason: Cyanosis at the nail beds indicates a lack of oxygen in the blood, but it is not specific to oxygen toxicity. It can occur in various conditions where there is inadequate oxygenation, such as chronic obstructive pulmonary disease (COPD) or heart failure.

Choice A reason: The first priority in this situation is to ensure the client’s airway is secure. Difficulty breathing and stridor indicate a potential airway obstruction, which can be life-threatening. Activating the hospital’s emergency or rapid response system ensures that the client receives immediate medical attention from a team equipped to handle such emergencies. This step is crucial to prevent respiratory arrest and other complications.

Choice B reason: While placing a heart monitor on the client and observing for dysrhythmias is important, it is not the immediate priority in this scenario. The client’s airway and breathing take precedence over monitoring heart rhythms. Once the airway is secured and breathing is stabilized, then monitoring for dysrhythmias can be considered.

Choice C reason: Asking the charge nurse to come see the client immediately is a reasonable action, but it is not the most effective first step. The charge nurse may not have the necessary equipment or expertise to handle an acute airway obstruction. Activating the emergency or rapid response system ensures that a specialized team responds quickly.

Choice D reason: Checking the client’s blood pressure and heart rate is important for overall assessment, but it is not the immediate priority when there is a potential airway obstruction. Ensuring the client can breathe is the most critical action. Vital signs can be checked once the airway is secured.

Choice E reason: Providing a calm and assuring environment for the client is beneficial for reducing anxiety, but it does not address the immediate threat to the client’s airway. While maintaining a calm environment is important, the nurse must first ensure the client’s airway is open and breathing is adequate.

Choice F reason: Placing the emergency cart at the bedside is a preparatory step that can be useful, but it is not the first action to take. The nurse should first activate the emergency or rapid response system to get immediate help. The emergency cart can be brought to the bedside by the responding team.