The female client is intubated and on a ventilator and the client's partner tells the nurse that she is very restless. Which should the nurse implement first?
1. Reassure the client with a soft, low voice.
2. Administer an antianxiety agent to client.
3. Check the client's SaO2 and blood pressure.
4. Explain that this is common client behavior.
3
3. Restlessness can be an indication of client anxiety; however, because the client is dependent on the ventilator for oxygenation and ventilation, the nurse assesses the client's oxygenation and vital signs and compares the findings with baseline data be-cause restlessness is also a common indicator of hypoxia. In addition, the nurse as-sesses the client's breath sounds, checks the ventilator settings, and rules out an air-way obstruction from secretions.
1. Reassuring the client is a reasonable nursing response; however, the most important nursing response is related to airway and breathing.
2. The nurse administers an antianxiety agent after eliminating all physiological causes of restlessness and remembers that restlessness is also an early indicator of infection.
4. Teaching is a reasonable intervention but must wait until the client is stable.
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