A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:
A. Has increased airway obstruction.
B. Has improved airway obstruction.
C. Needs to be suctioned.
D. Exhibits hyperventilation.
Correct Answer: A. Has increased airway obstruction.
The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.
Option B: Improvement in airway obstruction should decrease the presence of wheezes. Wheezing most often is caused by an obstruction (blockage) or narrowing of the small bronchial tubes in the chest. It can also be caused by an obstruction in the larger airways or vocal cords. The tone of the wheeze can vary depending on which part of the respiratory system is blocked or narrowed.
Option C: There is no indication for suctioning. Suctioning is used to obtain mucus and other fluids (secretions) and cells from the windpipe (trachea) and large airways (bronchi) and is typically used in people who are on mechanical ventilation or have problems with nerves or muscles that make coughing less effective for bringing up secretions.
Option D: Hyperventilation does not produce high pitched wheezes that extend throughout exhalation. The lowered carbon dioxide levels in the blood can cause squeezing of the airways, which then results in wheezing. Hyperventilation syndrome may cause the following chest symptoms like chest pains or tenderness, shortness of breath, and wheezing.