The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action?
a. Determine whether an air leak is present in the client's endotracheal tube cuff.
b. Have the respiratory therapist check the pressure settings.
c. Assess the client's oxygenation.
d. Manually ventilate the client with a resus-citation bag.
C
A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.
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