Question

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high pressure alarm is sounding. Which of the following actions should the nurse take first?

1) Assess the client's respiratory status
2) Administer a sedative medication
3) Increase the ventilator settings
4) Call the healthcare provider

Answer 1

The nurse's first action should be to assess the client's respiratory status when dealing with a high pressure alarm on a mechanical ventilator, as it is essential for determining the cause and deciding on further interventions.

Step-by-step explanation:

When caring for a client with emphysema who is on mechanical ventilation and appears anxious and restless, and the high pressure alarm is sounding, the first action a nurse should take is to assess the client's respiratory status. This is crucial for determining the cause of the alarm and the patient's discomfort. It may be due to a variety of factors such as a disconnection, obstruction, or the patient's respiratory efforts against the ventilator. Only after a thorough assessment, appropriate interventions such as adjusting the ventilator settings, administering medications, or contacting the healthcare provider can be carried out effectively.