A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Suction the client's airway.

Empty water from the client's ventilator tubing.

Increase the client's ventilator flow rate.

Evaluate the client for a cuff leak.

Answer and Explanation

The Correct Answer is D

D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.

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Correct Answer is B

Explanation

B. The client's PPD skin test result of 12 mm induration is considered positive for individuals who are at increased risk of tuberculosis, such as those with recent exposure to tuberculosis or immunocompromised individuals. A positive PPD result typically requires follow-up with a healthcare provider for further evaluation, which may include chest X-rays, sputum cultures, and treatment for latent tuberculosis infection if indicated.
A. Annual PPD testing may be indicated for certain populations, such as healthcare workers or individuals at high risk of exposure to tuberculosis. However, the decision to repeat the PPD test annually should be based on individual risk factors and healthcare provider recommendations.
C. The PPD skin test is typically read 48-72 hours after administration to assess for induration.
D. A PPD skin test result of 12 mm induration is considered positive for individuals at increased risk of tuberculosis, but it does not necessarily indicate that the test needs to be repeated immediately.

A. Blood pressure B. Echocardiogram results C. Respiratory rate D. Pain level E. Oxygenation saturation F. Urinary output G. Heart rate

Correct Answer is ["A","C","D","E","G"]

Explanation

Improvement in blood pressure would suggest better cardiovascular stability

A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.

An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.

A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.

A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.

Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.

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A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

Correct Answer is B

Explanation

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Correct Answer is ["A","C","D","E","G"]

Explanation

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