The nurse working in the intensive care unit is assigned a client requiring mechanical ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?
1. Silencing the alarm
2. Removing the client from the ventilator and using a bag-valve device to oxygenate the client until the respiratory therapist can be summoned
3. Emptying the collected water from the ventilator tubing
4. Assessing the client
4
Rationale 1: The alarm should not be silenced until the cause is determined.
Rationale 2: If the client is in distress, it might be necessary to remove the client from the ventilator and to bag the client until the cause of the problem can be located and corrected.
Rationale 3: If the client is comfortable, and assessment findings are within normal limits, the cause of the alarm could be water collecting in the tubing (which should be emptied).
Rationale 4: The nurse should treat the client and not the alarm, so the first action would be to assess the client quickly.
Global Rationale: The nurse should treat the client and not the alarm, so the first action would be to assess the client quickly. In most instances, depending on facility policy, if a client requires mechanical ventilation, he is placed on cardiorespiratory monitors with continuous oxygen saturation monitoring. The nurse would assess heart rate and oxygen saturation, and examine the client for any signs of distress. If the client is comfortable, and assessment findings are within normal limits, the cause of the alarm could be water collecting in the tubing (which should be emptied). However, if the client is in distress, it might be necessary to remove the client from the ventilator and to bag the client until the cause of the problem can be located and corrected.
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