A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A. "You will need to rest so that you can recover from the episode that brought you here.": This response dismisses the client's fear and does not address their concern about being given medications that induce sleep. It also does not acknowledge the client's right to refuse medications or address their autonomy.
B. "I will make sure that we respect your right to refuse medications.": This response validates the client's concern and reassures them that their autonomy and right to refuse medications will be respected. It promotes trust and therapeutic communication between the nurse and the client.
C. "It's not your choice to be here, so you have to accept the treatment we plan for you.": This response undermines the client's autonomy and rights, which can erode trust and impede therapeutic rapport. Involuntary admission does not negate the client's right to participate in treatment decisions or refuse medications.
D. "Why do you think your provider will prescribe you medications that will make you sleep?": This response challenges the client's perception and may come across as confrontational. It does not address the client's fear or provide reassurance about their rights regarding medication administration.

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.