Priority Nursing Action for Weaning from Mechanical Ventilation: Assessing Client Responses

The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action?1Assessing lung sounds every 15 minutes2Remaining with the client to assess responses3Monitoring the oxygen saturation levels frequently4Teaching the family members about ways to keep the client calm

In the given scenario, the priority nursing action for a client being weaned from mechanical ventilation is to remain with the client to assess responses (option 2)

In the given scenario, the priority nursing action for a client being weaned from mechanical ventilation is to remain with the client to assess responses (option 2). This is because weaning from mechanical ventilation can be a critical phase and requires close monitoring to evaluate the client’s tolerance to the procedure.

Option 1, assessing lung sounds every 15 minutes, is important as well, but it is not the top priority action. Though assessing lung sounds is an essential part of monitoring respiratory function, remaining with the client to assess responses allows for a more comprehensive evaluation of the client’s overall status, including breathing pattern, vital signs, and level of discomfort or distress.

Option 3, monitoring the oxygen saturation levels frequently, is also important, but it can be part of remaining with the client to assess responses. Oxygen saturation levels provide information about the client’s oxygenation status and can aid in determining the effectiveness of the weaning process. Oxygen saturation levels can be assessed using a pulse oximeter non-invasively and should be monitored regularly, but staying with the client takes precedence.

Option 4, teaching family members about ways to keep the client calm, is not the priority action in this scenario. While keeping the client calm is important for their overall well-being, it is not the immediate priority during the weaning process. Teaching the family can be done later once the client’s immediate needs and status have been addressed.

In summary, when a client is being weaned from mechanical ventilation, the priority nursing action is to remain with the client to assess their responses (option 2). This allows for a comprehensive evaluation of the client’s status, including respiratory function, vital signs, and overall well-being. Monitoring oxygen saturation levels frequently (option 3) is an important aspect of assessing the client’s respiratory status but can be part of staying with the client. Teaching family members about ways to keep the client calm (option 4) is important but is not the priority in this situation.

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