The nurse is caring for a client being weaned from the ventilator. When performing a spontaneous breathing trial, which item is not a priority assessment?
1. Mental status
2. Oxygen saturation
3. Vital signs
4. Ability to speak
Correct Answer: 4
The client might have a fenestrated tube or speaking valve that allows the client to communicate, but if neither of these is in place, the client would not speak. The ability to speak during a weaning trial is not as important as mental status, oxygen saturation, and vital signs, which indicate the client's tolerance of being removed from the ventilator.
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a. the ordinary reasonable midwife. b. the ordinary reasonable person. c. the ordinary reasonable obstetrician. d. the other defendants on trial.
What would you document about this incident?
What will be an ideal response?