A 52-year-old man recovering from a spinal cord injury is on a rehabilitation unit following a recent tracheostomy for prolonged ventilator weaning. He requires a mechanical lift for all transfers because of lower-extremity weakness. During morning care, the LPN/VN notes his respiratory rate is 28 breaths/min, SpO2 is 89% on his prescribed tracheostomy collar setting, heart rate is 112 beats/min, blood pressure is 138/84 mmHg, and he appears restless but is oriented to person, place, and time. Coarse, wet-sounding respirations are audible, and he is using accessory muscles to breathe. The LPN/VN's most recent recorded vital signs one hour ago showed SpO2 of 95% and respiratory rate of 18 breaths/min. Which action should the nurse take first?
- Adjust the ventilator flow settings to increase the client's delivered oxygen concentration.
- Document the vital sign changes in the medical record and continue with the scheduled care without notifying the RN.
- Suction the tracheostomy continuously for 30 seconds without preoxygenating the client first.
- Place the client in a high-Fowler position, suction the tracheostomy, and report the findings to the RN.