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
3
Rationale 1: The client might need the oxygen concentration increased however it should not be done before assessing the client.
Rationale 2: The client might need hyperoxygenated and hyperventilated however it should not be done before assessing the client.
Rationale 3: Assessing for airway obstruction should be done first.
Rationale 4: The ventilator setting may need checked but not before assessing the client.
Global Rationale: Assessing for airway obstruction should be done first. The client might need the oxygen concentration increased however it should not be done before assessing the client. The client might need hyperoxygenated and hyperventilated however it should not be done before assessing the client. The ventilator setting may need checked but not before assessing the client.
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Syncope is:
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