Question

A client who has emphysema 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?

A. Administer a bronchodilator
B. Assess the client's respiratory status
C. Suction the endotracheal tube
D. Notify the respiratory therapist

Answer 1

The nurse should first assess the client's respiratory status to determine the cause of the high-pressure alarm and the client's anxiety and restlessness.

Step-by-step explanation:

The nurse should take the action of assessing the client's respiratory status first when a client with emphysema who is receiving mechanical ventilation appears anxious and restless and the high-pressure alarm is sounding. This is because the high-pressure alarm indicates that there may be a problem with the client's respiratory function or the mechanical ventilator. By assessing the client's respiratory status, the nurse can determine if there is a need for intervention such as suctioning the endotracheal tube, administering a bronchodilator, or notifying the respiratory therapist.