A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)
Check for a disconnection in the ventilator tubing.
Assess the ET for a cuff leak.
Verify the placement of the ET
Check for a kink in the ventilator tubing.
Suction the ET to remove secretions
Correct Answer : D,E
Rationale:
A. Check for a disconnection in the ventilator tubing: A disconnection typically causes a low-pressure alarm, not an increase in peak airway pressure, and would not be the appropriate first response in this case.
B. Assess the ET for a cuff leak: A cuff leak would decrease airway pressure, potentially causing a low-pressure alarm. It is not associated with increased peak airway pressure alarms.
C. Verify the placement of the ET: ET tube misplacement can lead to ventilation issues, but it does not directly cause increased peak pressures unless malposition leads to obstruction, which would be less common.
D. Check for a kink in the ventilator tubing: A kink or obstruction in the tubing increases airway resistance and can cause high peak airway pressure alarms. Resolving the kink can restore normal pressure.
E. Suction the ET to remove secretions: Mucus plugging or secretion buildup increases resistance in the airway, raising peak pressures. Suctioning helps alleviate the obstruction and reduce alarm triggers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Limit visitors to 30 min per day: Time restrictions help minimize radiation exposure to visitors. Short visits reduce the cumulative dose received, which is especially important for non-staff individuals who are not regularly monitored for radiation exposure.
B. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant individuals should avoid close contact with radiation sources due to fetal sensitivity. Maintaining a 3-foot distance helps reduce exposure to scattered radiation from the sealed implant.
C. Wear a lead apron when providing care: A lead apron provides protection against scatter radiation, particularly during direct, prolonged care. Nurses should also stand as far away from the source as possible and work efficiently to limit time near the implant.
D. Place the client in a semi-private room: Clients with sealed radiation implants require a private room to protect others from radiation exposure. A semi-private room would place another patient at unnecessary risk and violates radiation safety protocols.
E. Close the door to the client's room: Keeping the door closed helps contain radiation within the room, thereby protecting other individuals in the surrounding area. It is a standard precaution for clients receiving internal radiation therapy.
Correct Answer is ["A","C","E","F"]
Explanation
Rationale:
A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.
B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.
C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.
D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.
E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).
F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.
G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.
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