24. A client has just been extubated. Which assessment by a nurse should indicate signs of laryngeal edema?
24. A client has just been extubated. Which assessment by a nurse should indicate signs of laryngeal edema?
. Diffuse, wheezing breath sounds.
. Arterial blood gases show a PCO2 of 52 mm Hg and PO 2 of 90%.
. Pulse oximeter of 91% with cool extremities.
. High-pitched crowing sounds on inspiration.
Test-Taking Tip
Focus on early signs. Vocal (laryngeal) sounds (Answer 4) would be the first, specific, and early sign of obstruction; all others are respiratory signs that would follow. Focus on the two answers that relate to nursing assessment of breath sounds. Select the answer that is a specific sign of obstruction.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because diffuse, wheezing breath sounds reflect bronchoconstriction, not laryngeal edema. Answer 2 is incorrect because arterial blood gases are not used to diagnose laryngeal edema. The alteration in vocal cord sounds is the first indication. The normal PCO2 is 35 to 45 mm Hg. A PCO2 of 52 mm Hg reflects respiratory acidosis. A PO2 of 90% at normal altitude is considered low-normal. Answer 3 is incorrect because a pulse oximetry reading reflects oxygen perfusion of the red blood cells. It may be decreased by severe vasoconstriction from decreased temperature, shock, or bleeding. It will not reflect the status of the larynx unless there is airway obstruction. Answer 4 is correct because the high-pitched crowing sounds, or stridor, are indications of edema of the larynx. Clients with this sign must be watched for obstruction and the need for possible re-intubation. Recognition of early signs of edema of the larynx prevents respiratory complications from occurring.