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 C
Explanation
A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.
Correct Answer is ["C","D","E","G"]
Explanation
The blood pressure is elevated. This may indicate a compensatory mechanism to try increases myocardial perfusion. However, this increases the oxygen demand worsening the condition.
Pain level of 7 indicates severe pain typical of acute coronary syndrome. The pain may worsen the extent of ischemia and hence morphine should be administered immediately
ECG findings are typical for myocardial infarction and intervention is key to prevent further myocardial damage.
Troponin levels are elevated due to damage of myocardium
Blood sugar level, bowel sounds and lung sounds are normal and therefore, requires no intervention.
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