Question

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first:

a) Administer a bronchodilator
b) Increase the ventilator rate
c) Suction the endotracheal tube
d) Assess the client's lung sounds

Answer 1

The nurse's first priority should be to assess the patient's lung sounds upon hearing a low exhaled volume alarm on a ventilator, as different lung sounds may indicate different underlying issues which require specific interventions.

Step-by-step explanation:

When a ventilator's low exhaled volume (low-pressure) alarm sounds and a client appears to be having respiratory difficulty, the nurse's first priority should be to assess the client's condition more comprehensively. This includes assessing the client's lung sounds to determine the potential cause of the respiratory difficulty. Symptoms such as crackling lung sounds could suggest pneumonia, whereas wheezing could indicate bronchospasm or obstruction. Both conditions would require different interventions. Administering a bronchodilator without first assessing the lung sounds could be unsafe if the issue is not related to bronchoconstriction, while increasing the ventilator rate or suctioning the endotracheal tube might not be appropriate without confirming the cause of the alarm.