A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?

Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.

Choice A reason: Suctioning the ET removes secretions obstructing airflow, increasing peak airway pressure. Mucus buildup narrows the airway, triggering alarms. Clearing secretions restores patency, reduces pressure, and prevents complications like atelectasis or hypoxia, critical for effective ventilation in mechanically ventilated clients.
Choice B reason: Verifying ET placement ensures the tube is in the trachea. Misplacement, like esophageal intubation, increases airway resistance, elevating peak pressure. Confirmation via capnography or X-ray prevents hypoxia, ensuring proper ventilation and safety in clients on mechanical ventilators.
Choice C reason: Checking for kinks in ventilator tubing addresses mechanical obstructions raising peak airway pressure. Kinks restrict airflow, triggering alarms. Straightening tubing restores normal gas delivery, reducing resistance and maintaining effective ventilation, preventing hypoxia in mechanically ventilated clients.
Choice D reason: Administering a bronchodilator relieves bronchospasm, a common cause of high peak airway pressure. Bronchoconstriction narrows airways, increasing resistance. Bronchodilators relax smooth muscles, improving airflow and reducing pressure, addressing reversible causes like asthma in ventilated clients.
Choice E reason: Increasing tidal volume exacerbates high peak airway pressure, risking barotrauma or lung injury by forcing air against resistance. Addressing underlying causes like secretions or bronchospasm is safer, as higher volumes do not resolve the root issue, potentially worsening outcomes.