A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

B. Assessing the client's vital signs, including blood pressure and pulse, provides critical information about the client's hemodynamic status and response to the new rhythm. Atrial fibrillation can lead to rapid, irregular heart rates and hemodynamic instability, so obtaining vital signs promptly helps the nurse determine the severity of the situation and whether immediate intervention is needed.

A. This action is not the priority when the nurse observes a new onset of atrial fibrillation. While beta- blockers such as metoprolol may be part of the client's long-term management for heart failure and atrial fibrillation, initiating medication administration without further assessment could delay appropriate intervention for the acute change in rhythm.

C. While it is important to communicate changes in the client's condition to the healthcare provider, this action should occur after the nurse has assessed the client's vital signs and determined the urgency of the situation. If the client is stable and responsive to initial interventions, the nurse can then contact the healthcare provider to discuss the new onset of atrial fibrillation and collaborate on further management.

D. Documenting the changes in the client's rhythm is important for continuity of care and communication among healthcare team members. However, obtaining a rhythm strip should not be the first action when a new onset of atrial fibrillation is observed. Assessing the client's vital signs and initiating appropriate interventions to address any hemodynamic instability take precedence.

D. Oral hygiene is crucial in reducing the risk of VAP as it helps to reduce the bacterial load in the oral cavity, which can be aspirated into the lower respiratory tract. Using a suction toothbrush to mechanically remove dental plaque and bacteria from the teeth and oral mucosa can help to prevent VAP.

A. Elevating the head of the bed to between 30 and 45 degrees (semi-recumbent position) is recommended to prevent aspiration of oral or gastric contents, which can contribute to the development of VAP. This position helps to promote drainage of secretions and reduces the risk of reflux.

B. While maintaining appropriate humidity levels in the ventilator tubing helps to prevent drying of the respiratory mucosa and promote secretion clearance, it does not directly reduce the risk of VAP. Other interventions are more directly related to VAP prevention.

C. Regular turning and repositioning of the client help to prevent pooling of secretions, improve ventilation-perfusion matching, and reduce the risk of pressure ulcers. Turning the client every 2 hours is often recommended to optimize lung expansion and secretion clearance, thereby reducing the risk of VAP.