The nurse is providing care for a client requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the client's monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?
1. Increasing the oxygen concentration and quickly assessing the client
2. Removing the client from the ventilator and hyperoxygenating and hyperventilating the client
3. Assessing the client for airway obstruction
4. Checking ventilator settings
Correct Answer: 3
Remembering the nursing process, the nurse would not intervene until assessing for the cause of the client's distress. All of the actions described might be the next priority action, but first and foremost, the nurse must assess the client.
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