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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Proteinuria is a hallmark finding in nephrotic syndrome. Proteinuria refers to the presence of excess protein, particularly albumin, in the urine. It occurs due to increased permeability of the glomerular filtration barrier, allowing proteins to leak into the urine rather than being retained in the bloodstream.
A. Individuals with nephrotic syndrome may be at an increased risk of thrombosis (formation of blood clots) due to loss of anticoagulant proteins such as antithrombin III in the urine.
C. Nephrotic syndrome is characterized by hypoalbuminemia, which is a decreased level of albumin in the bloodstream. The loss of albumin in the urine leads to decreased serum albumin levels, contributing to edema formation and other complications associated with nephrotic syndrome.
D. Decreased serum lipid levels is not a typical finding in nephrotic syndrome. In fact, individuals with nephrotic syndrome often have dyslipidemia, characterized by elevated serum lipid levels, including cholesterol and triglycerides.
Correct Answer is D
Explanation
D. Hanging a monthly calendar in the client's bedroom provides a visual aid for tracking important dates and events, which can help maintain their sense of routine and structure.
A. Keeping the client's bedroom dark at night may increase confusion and disorientation, especially if the client wakes up during the night.
B. Placing a large-face clock in the client's bedroom allows them to easily see and understand the time, which can help orient them to the day and reduce confusion. However, it may become monotonous for the client.
C. While it's essential to childproof the home to prevent accidents, covering electrical outlets with tape may not effectively prevent access to them and can pose a fire hazard.
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