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

Suction secretions from the endotracheal tube.

Check the ventilator tubing connections.

Administer intravenous sedation and analgesia.

Reassure the client and instruct them not to bite on the tube.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Suctioning secretions from the endotracheal tube is a common intervention for high-pressure alarms, which indicate an obstruction in the airway. However, a low-pressure alarm typically signals a disconnection or leak in the ventilator system, not an obstruction.

Choice B Reason:

Checking the ventilator tubing connections is the appropriate response to a low-pressure alarm. This alarm usually indicates a disconnection or leak in the ventilator circuit, which can compromise the delivery of adequate ventilation to the patient. Ensuring all connections are secure is the first step in troubleshooting this issue.

Choice C Reason:

Administering intravenous sedation and analgesia is not directly related to addressing a low-pressure ventilator alarm. While sedation may be necessary for patient comfort and to prevent agitation, it does not resolve the underlying issue of a disconnection or leak in the ventilator system.

Choice D Reason:

Reassuring the client and instructing them not to bite on the tube is more relevant to high-pressure alarms, where patient actions such as biting the tube can cause increased airway resistance. It does not address the cause of a low-pressure alarm, which is typically due to a disconnection or leak.

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Correct Answer is C

Explanation

Choice A Reason

Lidocaine is primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. It is not typically used for bradycardia (a heart rate of 40/min) and would not be appropriate for this scenario.

Choice B Reason

Adenosine is used to treat certain types of supraventricular tachycardia (SVT) by slowing down the heart rate. It is not indicated for bradycardia and would not be suitable for a heart rate of 40/min.

Choice C Reason

Atropine is the first-line medication for treating symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Given the client’s symptoms of a low heart rate, diaphoresis, and chest pain, atropine is the appropriate choice.

Choice D Reason

Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain types of arrhythmias. However, it is not used for bradycardia and could potentially worsen the condition by further lowering the heart rate.

A. Diazepam IV B. Lorazepam PO C. Diltiazem IV D. Clonazepam PO

Correct Answer is A

Explanation

Choice A Reason

Diazepam IV is the correct choice for managing repeated tonic-clonic seizures, especially in the context of status epilepticus. Diazepam is a benzodiazepine that acts quickly to stop seizures by enhancing the effect of the neurotransmitter GABA. It is commonly used in emergency settings due to its rapid onset of action when administered intravenously.

Choice B Reason

Lorazepam PO is not the best choice in this scenario. While lorazepam is also a benzodiazepine effective in stopping seizures, the oral route is not suitable for immediate control of seizures. Intravenous administration is preferred for rapid action.

Choice C Reason

Diltiazem IV is incorrect. Diltiazem is a calcium channel blocker used primarily for managing hypertension and certain types of arrhythmias. It is not indicated for the treatment of seizures.

Choice D Reason

Clonazepam PO is not appropriate for immediate seizure control. Although clonazepam is a benzodiazepine used for seizure management, the oral route is not effective for rapid seizure termination. Intravenous administration of a benzodiazepine like diazepam or lorazepam is preferred.

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

Nursing Test Bank

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