An adult patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm is frequently being triggered. Which of the following interventions would the nurse do first? 1.25 Points

A. Assess the client for a physiologic reason for his agitation is correct because agitation in an intubated, mechanically ventilated patient can indicate hypoxia, hypercapnia, pain, airway obstruction, or other acute physiologic problems. High-pressure alarms are often triggered by secretions, bronchospasm, coughing, or patient-ventilator dyssynchrony, and these causes must be identified and corrected immediately before implementing sedation or restraints. Assessment is always the first step in the nursing process. B. Administer a bolus dose of IV antianxiolytic is incorrect because giving medication without first determining the underlying cause could mask important signs of deterioration, such as hypoxia or ventilator obstruction. Sedation is secondary to addressing the primary physiologic problem. C. Obtain a stat ABG is incorrect as the first action because while ABGs provide important data about oxygenation and ventilation, the immediate cause of agitation and high ventilator pressures needs to be addressed first, such as suctioning secretions or checking tubing. ABGs can follow after rapid assessment and interventions. D. Apply soft wrist restraints is incorrect because restraints do not treat the underlying cause of agitation and may worsen anxiety or increase oxygen demand. Restraints are considered only if the patient poses a risk of self-harm or removing the endotracheal tube after addressing physiologic needs.