A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. The ventilator's high-pressure alarm suddenly begins to sound continuously. Arrange the following nursing actions in the most appropriate chronological order from first to last.
- 1Assess the client's oxygen saturation, chest excursion, and level of distress.
- 2Inspect the endotracheal tube for biting and the ventilator tubing for kinks.
- 3Auscultate the lung fields bilaterally for adventitious breath sounds.
- 4Perform in-line endotracheal suctioning to remove accumulated secretions.
- 5Reassess the client's respiratory status and ensure the ventilator alarm has ceased.
Answer
The correct sequence prioritizes immediate client assessment, followed by checking for mechanical obstructions, assessing for physiological causes, intervening via suctioning, and finally evaluating the response.
The correct sequence follows the foundational nursing process and prioritization rules for critical care. The nurse must always assess the client first to rule out immediate life-threatening distress. Once the client's baseline is established, the nurse checks for simple external mechanical issues such as tubing kinks or biting of the endotracheal tube. If those are clear, a deeper clinical assessment via auscultation is performed to identify internal causes like excessive secretions. After identifying the cause, the nurse intervenes by suctioning and then evaluates the effectiveness of the action through reassessment.
Step-by-Step Solution
Key Concept
Nursing prioritization during mechanical ventilator alarms emphasizes assessing the client first, troubleshooting mechanical issues second, and following the nursing process (Assessment, Intervention, Evaluation).