Final answer:
The nurse's first action for a mechanically ventilated ICU patient showing restlessness should be to auscultate bilateral breath sounds to check for proper ventilation and respiratory issues.
Step-by-step explanation:
When a client in the intensive care unit (ICU) being mechanically ventilated exhibits signs of restlessness, the first action a nurse should take is to auscultate bilateral breath sounds. This is important to ensure that the mechanical ventilation is functioning properly, and the patient is adequately ventilated. Restlessness can be a sign of hypoxia or other respiratory issues, which must be addressed immediately for the safety of the patient.
If the breath sounds are normal and no issues are found there, then the nurse may proceed with the other actions such as reviewing the heart rhythm on the cardiac monitor, administering a PRN dose of lorazepam, or checking the urinary catheter for obstruction, depending on the patient's clinical situation and other symptoms presented.
Your question seems incomplete. The completed version is:
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
a. Auscultate bilateral breath sounds
b. Review the heart rhythm on cardiac monitor
c. Administer PRN dose of lorazepam
d. Check urinary catheter for obstruction