QuestionJune 4, 2025

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding. A. An audible voice when client is trying to communicate. B. Diminished breath sounds In the right posterior base. C. Restrained and restless with a low volume alarm sounding. D. High pressure alarm sounds when client is coughing.

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding. A. An audible voice when client is trying to communicate. B. Diminished breath sounds In the right posterior base. C. Restrained and restless with a low volume alarm sounding. D. High pressure alarm sounds when client is coughing.
The nurse is managing 4 clients in the intensive care unit who are mechanically
ventilated.
After performing a quick visual assessment, the nurse should prioritize care for the
client who is exhibiting which finding.
A. An audible voice when client is trying to communicate.
B. Diminished breath sounds In the right posterior base.
C. Restrained and restless with a low volume alarm sounding.
D. High pressure alarm sounds when client is coughing.

Solution
4.3(220 votes)

Answer

C. Restrained and restless with a low volume alarm sounding. Explanation 1. Identify Critical Condition The most critical condition is when a low volume alarm sounds, indicating potential disconnection or obstruction in the ventilator circuit, which can lead to inadequate ventilation. 2. Prioritize Based on Severity Among the options, option C (Restrained and restless with a low volume alarm sounding) suggests an immediate threat to airway patency or ventilation, requiring urgent attention.

Explanation

1. Identify Critical Condition<br /> The most critical condition is when a low volume alarm sounds, indicating potential disconnection or obstruction in the ventilator circuit, which can lead to inadequate ventilation.<br /><br />2. Prioritize Based on Severity<br /> Among the options, option C (Restrained and restless with a low volume alarm sounding) suggests an immediate threat to airway patency or ventilation, requiring urgent attention.
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