The nurse receives change-of-shift report on four clients in a ventilator weaning unit. Which client should the nurse assess first?

An orally intubated client is being prepared for a spontaneous breathing trial. The client’s sedation has been decreased. The ventilator is set at 16 breaths/min. The client becomes restless, the respiratory rate increases from 18 to 28 breaths/min, and the high-pressure alarm sounds intermittently. SpO₂ remains 94%. Which action should the nurse take first?

A mechanically ventilated client develops a high-pressure alarm. The nurse notes coarse rhonchi bilaterally, visible secretions in the endotracheal tube, and SpO₂ has decreased from 96% to 91%. The ventilator tubing is not kinked. Which action should the nurse take?

A client with acute respiratory distress is placed on high-flow oxygen. Which finding 15 minutes later provides the strongest evidence that respiratory support should be escalated?

The RN is coordinating care for several clients on a medical-surgical unit. Which task is most appropriate for the RN to delegate to an LPN?

A mechanically ventilated client with an endotracheal tube has bilateral soft wrist restraints to prevent unplanned extubation. During the nurse’s assessment, which finding requires priority intervention?

A client with ARDS is receiving mechanical ventilation. The high-pressure alarm sounds. SpO₂ decreases from 94% to 86%, RR increases to 32/min, and the client becomes increasingly restless. The nurse confirms that the ventilator tubing is connected and not kinked. Which action should the nurse take first?

A client undergoing a spontaneous breathing trial (SBT) develops a respiratory rate of 34/min, increased accessory-muscle use, restlessness, and an SpO₂ of 87%. Which action should the nurse take first?

A mechanically ventilated client is receiving a neuromuscular blocking agent for severe ventilator dyssynchrony. Which finding requires the nurse’s immediate intervention?

A client who was orally intubated for pneumonia is receiving assist-control ventilation. Settings are RR 14/min, VT 400 mL, FiO₂ 40%, and PEEP 5 cm H₂O. The ventilator displays a low exhaled tidal-volume alarm. Exhaled tidal volume is 220 mL, an audible air leak is heard around the endotracheal tube, and SpO₂ has decreased from 95% to 91%. Which action should the nurse take first?