A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Choice A rationale:

Tightening the tubing connections may be necessary if there is a leak in the ventilator system, but it does not address the high-pressure alarm issue. The nurse needs to address the immediate alarm situation first.

Choice B rationale:

Requesting insertion of a tracheostomy tube is not the appropriate action for a high-pressure alarm on the ventilator. Tracheostomy tube insertion is a significant procedure that is not indicated solely based on a high-pressure alarm.

Choice C rationale:

Suctioning the client's airway is the correct action for a high-pressure alarm on the ventilator. The alarm indicates an obstruction in the airway, and suctioning can help clear any secretions or blockages, allowing the client to breathe more effectively.

Choice D rationale:

Looking for a leak in the tube's cuff may be necessary if the high-pressure alarm persists after suctioning and checking connections. Identifying and repairing any leaks can prevent further issues with ventilation. However, immediate action should be taken to clear the airway first, as indicated by suctioning.

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.