A nurse is caring for a client immediately following endotracheal intubation. The nurse should assess the client for complications by performing which of the following priority action?

A. Evaluate outcomes at the end of the shift: This is an important recommendation as it allows nurses to assess the effectiveness of interventions and the overall condition of patients. Evaluating outcomes helps in identifying areas for improvement, ensuring that patient care meets safety and quality standards. This practice fosters accountability and continuous improvement in patient-centered care.
B. Evaluate outcomes at the start of the shift: While evaluating outcomes at the beginning of the shift can provide valuable information, it is more effective to evaluate outcomes after care has been provided. Starting the shift with a review of previous outcomes can guide care planning, but the actual evaluation of interventions should occur after implementation to assess their effectiveness.
C. Plan and report outcomes: Planning and reporting outcomes are essential components of providing safe, quality, patient-centered care. This involves setting clear goals for patient care and documenting the expected results, which allows for effective communication among the healthcare team and ensures that everyone is aligned in their approach to patient care.
D. Communicate the plan: Effective communication of the care plan is critical to patient safety and quality care. Sharing the plan with all team members ensures that everyone is aware of the goals and interventions, facilitating collaboration and reducing the risk of errors. Clear communication enhances the patient's understanding of their care and promotes involvement in the decision-making process.
E. Think critically: Critical thinking is fundamental to nursing practice and promotes safe, quality, patient-centered care. It involves analyzing information, evaluating evidence, and making informed decisions based on patient needs and circumstances. Encouraging critical thinking enables nurses to assess situations thoroughly, anticipate potential problems, and implement appropriate interventions.

A. Prepare to assist with intubation of the client: This action should be prioritized for a client diagnosed with acute respiratory distress syndrome (ARDS). ARDS can lead to significant respiratory distress and hypoxemia, requiring advanced airway management. Assisting with intubation ensures that the client receives adequate ventilation and oxygenation, which is critical in managing ARDS effectively. Immediate preparation for intubation is essential to prevent further deterioration of the client’s respiratory status.
B. Place a tracheostomy tray at the client's bedside: While having a tracheostomy tray available can be important in cases of prolonged respiratory failure, this action is not the immediate priority. The focus should be on ensuring proper airway management and oxygenation first. A tracheostomy is typically considered if the client requires long-term ventilation, but initial intervention for ARDS often involves intubation.
C. Administer IV prophylaxis for thromboembolism: While providing prophylaxis for thromboembolism is important in the overall management of patients at risk, especially in those with limited mobility, it is not the first priority in an acute situation. The immediate need is to address the client’s respiratory distress and ensure proper ventilation.
D. Administer IV prophylaxis for stress ulcers: Providing prophylaxis for stress ulcers is also a relevant consideration, particularly in critically ill patients. However, it is not an urgent action compared to securing the airway and ensuring effective oxygenation. Addressing respiratory failure and maintaining airway patency should take precedence in the acute management of ARDS.