A client in the recovery ICU is on mechanical ventilation. The nurse notices the client has frothy secretions around his mouth, and the nurse hears adventitious breath sounds with the stethoscope. The nurse should

  1. increase the oxygen level on the ventilator.
  2. suction the endotracheal tube.
  3. lower the head of the bed.
  4. call the rapid response team.
Number 2 is correct.
Rationale: A client on mechanical ventilation may experience secretions that require suctioning. The nurse should watch for signs that the client needs to be suctioned, such as visible secretions, adventitious breath sounds, and restlessness. Increasing oxygen and lowering the head of the bed are not therapeutic interventions for the symptoms that the patient is experiencing. The rapid response team is not indicated unless the patient is in distress.