Difficulty: Medium
Average Score: 94%
Simulated
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Correct answer
C
Rationale
High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.