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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An antibiotic that can cause nephrotoxicity is an antibiotic that can damage the kidneys, which are the organs that filter the blood and remove waste products and excess fluid from the body. Some examples of nephrotoxic antibiotics are aminoglycosides, vancomycin, amphotericin B, and sulfonamides.
Serum creatinine is a laboratory value that measures the amount of creatinine in the blood. Creatinine is a waste product that is produced by the breakdown of muscle tissue and is normally excreted by the kidneys. A high serum creatinine level indicates that the kidneys are not functioning properly and are unable to filter out the creatinine from the blood.
Before administering an antibiotic that can cause nephrotoxicity, it is important for the practical nurse (PN) to review the serum creatinine level of the client, as it reflects the kidney function and the risk of nephrotoxicity. A normal serum creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. If the serum creatinine level is elevated, it may indicate that the client has impaired kidney function or is developing nephrotoxicity from the antibiotic. In this case, the PN should notify the primary healthcare provider and monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, or electrolyte imbalances .
Correct Answer is D
Explanation
A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.
B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.
C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.
D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.
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