Practice Question
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
Answer Choices:
Correct Answer:
Assess the cause of the agitation.
Rationale:
🟩 Agitation in a mechanically ventilated client is often a symptom of an underlying problem, such as hypoxia, pain, anxiety, or tube displacement.
🟩 Immediate assessment helps determine whether life-threatening complications, such as hypoventilation or accidental extubation, are present.
🟩 Prioritizing assessment follows the nursing process and avoids masking the true cause with sedation or restraints.
🟩 Unaddressed causes of agitation can compromise oxygenation or increase ventilator asynchrony.
🟩 Once the cause is identified, targeted interventions can safely calm the patient.
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This question is from ATI LPN Medical surgical(Monroe College) which contains 37 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Medical-Surgical
- Answer Choices: 4