The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding and cannot quickly identify the cause of the alarm. The nurse's priority action is to:
Explanation & Rationale
A. While involving the respiratory therapist is appropriate, obtaining a new ventilator does not immediately address the patient’s need for oxygenation and ventilation. Delaying manual ventilation could result in hypoxia or respiratory compromise. B. When a high-pressure alarm sounds and the cause is unknown, the patient may not be receiving adequate ventilation. The priority is to ensure oxygenation and ventilation by manually ventilating with a bag-valve-mask (BVM). This stabilizes the patient while the nurse or respiratory therapist identifies and corrects the underlying issue, such as secretions, kinking of the tubing, or bronchospasm. This action follows the principle of airway, breathing, circulation (ABC) in critical care. C. Although the patient may need further assessment, waiting for the rapid response team before providing immediate ventilation could delay critical intervention and compromise oxygenation. Rapid response may assist once the patient is stabilized. D. Searching for the cause without first ensuring adequate ventilation risks patient hypoxia and deterioration. Identifying the problem is important, but patient stabilization takes priority over troubleshooting.