A nurse at a long-term care facility is reviewing prescriptions for a client receiving mechanical ventilation. Which of the following interventions should the nurse identify as the priority?

A. Nasal cannulas deliver a low flow rate of oxygen, which means the concentration of oxygen delivered is not constant and can vary depending on the client's breathing rate and depth.
B. Nasal cannulas are designed to be worn continuously, and removing them can disrupt the delivery of oxygen and potentially worsen the client's condition.
C. Nasal cannulas are typically used to deliver low concentrations of oxygen, which is often sufficient for patients with mild to moderate respiratory conditions.
D. Nasal cannulas cannot deliver the highest concentration of oxygen possible. For patients who require higher concentrations of oxygen, other delivery methods, such as a face mask or mechanical ventilation, may be necessary.

A. While it might seem reasonable to increase oxygen flow, the nurse first needs to assess the client's respiratory status before making changes to the oxygen therapy. Simply increasing the oxygen without assessing the cause of the difficulty may not address the underlying issue.
B. Pursed-lip breathing can help improve ventilation and reduce feelings of breathlessness, especially in COPD patients. However, before instructing this technique, the nurse should first evaluate the client's condition to ensure it is appropriate and effective in this situation.
C. Assessing the client's respiratory status is essential to determine the cause of the difficulty breathing. This includes checking the respiratory rate, depth, use of accessory muscles, oxygen saturation, and lung sounds.
D. While encouraging the client to cough and expectorate can help clear secretions and improve breathing, it should follow an initial assessment of the respiratory status.