While assessing a patient who has just arrived from the Post Anesthesia Care Unit (PACU), the nurse hears stridor. What is the first action the nurse should take?

Choice A rationale:
Incorrect. Deep-breathing exercises could potentially worsen stridor. Stridor is a high-pitched, wheezing sound caused by a partial obstruction of the upper airway. Deep breathing can increase airflow through the narrowed airway, making the stridor more pronounced and potentially worsening the obstruction. In severe cases, it could lead to complete airway obstruction and respiratory distress.
Risk of aggravation: Deep-breathing exercises could aggravate the underlying cause of stridor, such as laryngeal edema or vocal cord dysfunction, by increasing inflammation or muscle tension in the airway.
Delay in definitive treatment: Focusing on deep-breathing exercises might delay more definitive interventions, such as intubation, which might be necessary to secure the airway and prevent respiratory failure.
Choice B rationale:
Incorrect. While albuterol nebulizer therapy can be helpful for bronchospasm, it is not the first-line treatment for stridor. Stridor is typically caused by an upper airway obstruction, and albuterol primarily targets the lower airways (bronchioles).
Limited effectiveness: Albuterol might not be effective in reducing stridor caused by upper airway obstruction, as it does not directly address the narrowing of the airway.
Potential for adverse effects: Albuterol can cause tachycardia, tremors, and anxiety, which could further complicate the patient's condition.
Choice C rationale:
Not the most immediate action. While calling a Rapid Response might be necessary if the patient's condition deteriorates, the first priority is to secure the airway and ensure adequate ventilation.
Time-consuming: Activating a Rapid Response team can take several minutes, and the patient's condition might not allow for that delay.
Choice D rationale:
Prioritizes airway management: Intubation is the most effective way to secure the airway and ensure adequate ventilation in a patient with stridor. It bypasses the obstruction and allows for controlled delivery of oxygen and ventilation.
Addresses potential for deterioration: Stridor can rapidly progress to complete airway obstruction, so prompt preparation for intubation is crucial to prevent respiratory failure.
Involves the primary healthcare provider: Consulting the primary health care provider ensures timely decision-making, appropriate medication administration (such as sedatives or paralytics for intubation), and coordination of care.