A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?

Following extubation, close respiratory assessment is essential because airway compromise can develop rapidly. Nurses must monitor for signs of upper airway obstruction, impaired oxygenation, and respiratory distress. Some findings such as mild sore throat are expected, while others indicate a potentially life-threatening emergency requiring immediate intervention. Early recognition of airway obstruction is critical to prevent respiratory failure and the need for reintubation. A. Stridor is a high-pitched inspiratory sound that indicates upper airway obstruction, often caused by laryngeal edema or swelling after extubation. This finding suggests narrowing of the airway and can rapidly progress to complete obstruction if untreated. Immediate intervention is required to maintain airway patency and prevent respiratory arrest. B. Sore throat is a common and expected finding after extubation due to irritation of the pharynx and larynx from the endotracheal tube. It is usually mild and resolves with supportive care such as hydration and throat comfort measures. It does not require urgent intervention unless accompanied by airway compromise. C. Rhonchi are low-pitched breath sounds caused by secretions in the larger airways and may occur after extubation if mucus remains present. They often improve with coughing, suctioning, or repositioning. Although they require assessment, they are less immediately dangerous than signs of upper airway obstruction such as stridor. D. An SaO2 of 92% may be slightly lower than ideal but can be acceptable depending on the client’s baseline condition and overall respiratory status. It requires monitoring and possibly supplemental oxygen, but it is not as urgent as evidence of airway obstruction. Stridor takes priority because airway patency must always be addressed before oxygenation concerns.