A nurse identifies rhonchi over the trachea and bronchi. Which action should the nurse take?

A nurse identifies rhonchi over the trachea and bronchi. Which action should the nurse take?

• A. Administer oxygen at 2 L/min
• B. Encourage the client to cough
• C. Limit the client's fluid intake
• D. Assist the client into a supine position

Answer: (B)

Rhonchi in the trachea and bronchi point to mucus in the large airways causing continuous rough, rattling sounds as air moves. The priority is to clear those secretions to improve airway patency and ventilation. Encouraging the client to cough helps loosen and mobilize mucus, making it easier to expectorate. This directly addresses the source of the noise and the obstruction, improving air flow. Supportive context: keeping secretions thin with adequate hydration and positioning to aid drainage also helps, but the immediate action tied to the presence of rhonchi is to stimulate coughing to clear the airways. Oxygen therapy is appropriate if there’s low oxygen saturation or distress, not as the first response to rhonchi alone. Limiting fluids would make secretions thicker and harder to clear, and lying supine can worsen drainage and breathing effort, so a more upright position is preferred.

Rhonchi in the trachea and bronchi point to mucus in the large airways causing continuous rough, rattling sounds as air moves. The priority is to clear those secretions to improve airway patency and ventilation. Encouraging the client to cough helps loosen and mobilize mucus, making it easier to expectorate. This directly addresses the source of the noise and the obstruction, improving air flow.

Supportive context: keeping secretions thin with adequate hydration and positioning to aid drainage also helps, but the immediate action tied to the presence of rhonchi is to stimulate coughing to clear the airways. Oxygen therapy is appropriate if there’s low oxygen saturation or distress, not as the first response to rhonchi alone. Limiting fluids would make secretions thicker and harder to clear, and lying supine can worsen drainage and breathing effort, so a more upright position is preferred.