A nurse is caring for a client who is mechanically ventilated and is agitated. The nurse notices the client attempts to reach the endotracheal tube. Which of the following actions should the nurse take?

Rationale: A. Verify the alarm settings on the ventilator: Ensuring alarms are properly set is a routine safety check but does not directly address the client's agitation or risk of self-extubation. It is important but not the priority action in this scenario. B. Turn on the television: Providing distraction may help reduce mild anxiety but is insufficient for managing significant agitation in a mechanically ventilated client who may become dangerous to themselves if they pull out the endotracheal tube. C. Obtain a prescription for a vest restraint: Physical restraints should be a last resort after attempting less restrictive methods. Using restraints without addressing the underlying cause of agitation (e.g., discomfort, anxiety, pain) can increase distress and injury risk. D. Administer a sedative medication: Sedation is appropriate for a mechanically ventilated client who is agitated and at risk for self-extubation. Sedatives help ensure patient comfort, reduce anxiety, and promote ventilator synchrony while protecting the airway.