A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?
Re-evaluate the client for an ET cuff leak.
Assess for disconnected tubing.
Decrease the ventilator flow rate.
Deliver breaths manually with a resuscitation bag.
The Correct Answer is D
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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The client is at risk for experiencing electrolyte imbalance due to the vomiting. Persistent vomiting during pregnancy, especially with significant weight loss, can lead to electrolyte imbalances such as hypokalemia, hyponatremia, or metabolic alkalosis. This can result from the body's inability to retain essential minerals and fluids. The client’s reported diet of minimal food intake, primarily consisting of toast and pretzels, indicates inadequate nutrition and potential for further exacerbation of these imbalances.
The significant weight loss of 6.8 kg (15 lb) within a month and continuous nausea and vomiting are concerning symptoms that warrant immediate medical evaluation. The nurse’s advice to seek a provider’s assessment underscores the need for timely intervention to address potential complications, ensure maternal and fetal health, and possibly prescribe antiemetic medications or other treatments to manage symptoms.
Correct Answer is A
Explanation
A.Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.
B.While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.
C.Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.
D.While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily afinding that would prevent surgery.
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