Nokea
A 45-year-old postsurgical patient is on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The apbairtbi.ecnomt /bteesct omes tachycardic and hypertensive with a respiratory rate that has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV ) at a rate of 10 breaths/min. The patient has been suctioned recently via existing endotracheal tube until airway is clear. When the patient responds appropriately to the nurse’s command s, what should be the nurse’s priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Assessing the patient's level of pain. In this situation, the patient's tachycardia, hypertension, and increased respiratory rate could be indicative of pain. By assessing the patient's pain level, the nurse can address any discomfort the patient may be experiencing, which could be contributing to these physiological responses.
Summary of other choices:
B: Decreasing the SIMV rate on the ventilator - This is not the priority intervention as the patient's symptoms are more likely related to pain rather than the ventilator settings.
C: Providing sedation as ordered - Sedation is not the priority in this case as the patient has been tolerating the ventilator well without requiring sedation.
D: Suctioning the patient again - Since the airway has been recently cleared, suctioning again is not necessary at this point and would not address the underlying cause of the patient's symptoms.