When a mechanical ventilator's high-pressure alarm sounds, what is the nurse's first action?

When a mechanical ventilator's high-pressure alarm sounds, the nurse's first action should be to assess the client's condition. This step is crucial because it allows the nurse to determine the underlying cause of the alarm. High-pressure alarms can indicate various issues such as airway obstruction, changes in lung compliance, or a patient-related problem. By assessing the client, the nurse can gather vital information, such as the patient's respiratory rate, oxygen saturation, and any signs of distress, which are essential for making informed decisions about further intervention.

Relying on assessment first ensures that the nurse addresses the most immediate concern—the patient’s safety and well-being—before taking subsequent actions related to the alarm. After assessment, it may be appropriate to reset the alarm, use a resuscitation bag, or contact a respiratory therapist based on the findings from the assessment.