Question

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately?

Answer 1

A nurse should report shortness of breath, wheezes or stridor, severe pain with swallowing, excessive coughing, or significant changes in oxygen saturation immediately to the healthcare provider after a patient is extubated.

Step-by-step explanation:

After extubation and being placed on a 50% non-rebreather mask, hoarseness and a sore throat are common complaints due to irritation from the endotracheal tube. However, a nurse should report immediately to the healthcare provider if the client exhibits symptoms such as shortness of breath, wheezes or stridor, difficulty speaking, or changes in voice beyond a mild hoarseness. These symptoms could indicate serious complications like upper airway obstruction or laryngeal edema. Other critical signs to watch for post-extubation include severe pain with swallowing, excessive coughing, or a significant change in oxygen saturation levels as these could suggest respiratory complications or aspiration.