A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

Choice A reason

Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.

Choice B reason:

Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.

Choice C reason:

Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.

Choice D reason:

When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.