A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal (ET) tube and the high-pressure alarm is beeping. The client is experiencing respiratory distress, and the nurse is unable to determine the cause. Which of the following actions should the nurse take?

Rationale: A. A high-pressure alarm on a mechanical ventilator usually indicates increased resistance to airflow (such as secretions, kinking of the tubing, biting the tube, or bronchospasm), not disconnection. A disconnected tube would typically trigger a low-pressure alarm, not a high-pressure alarm. While assessment is important, it should not delay immediate life-saving intervention when the client is in respiratory distress. B. This is the correct priority action because the client is in respiratory distress and the cause of the high-pressure alarm is unknown. Manual ventilation using a bag-valve-mask (or resuscitation bag attached to oxygen) ensures the client continues to receive oxygen while the nurse quickly assesses and resolves the cause of increased airway resistance. This is an immediate life-saving intervention and follows ABCs (Airway, Breathing, Circulation). C. An endotracheal cuff leak is associated with a low-pressure alarm and inadequate ventilation, not a high-pressure alarm. Therefore, this is not the appropriate focus for this situation. D. While agitation or biting the tube may contribute to increased airway pressure, increasing sedation is not the immediate priority. The nurse must first ensure oxygenation and ventilation before addressing possible causes such as agitation.