A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

The patient may need suctioning

The patient extubated himself

The ventilator tubing may be disconnected.

The cuff at the end of the endotracheal tube is deflated.

Answer and Explanation

The Correct Answer is A

A. The patient may need suctioning:
A high-pressure alarm indicates increased resistance to airflow, which could be caused by secretions or mucus in the airways. Suctioning is the appropriate intervention to clear the airways of excess secretions, reducing airway resistance and preventing the high-pressure alarm.

B. The patient extubated himself:
If the patient extubates himself (removes the endotracheal tube), this may result in a low-pressure alarm, not a high-pressure alarm. The low-pressure alarm is triggered when there is a loss of pressure within the ventilator circuit due to disconnection or extubation.

C. The ventilator tubing may be disconnected:
If the ventilator tubing is disconnected, it is more likely to trigger a low-pressure alarm, indicating a loss of pressure in the ventilator circuit. This is not the primary cause of increased resistance seen with a high-pressure alarm.

D. The cuff at the end of the endotracheal tube is deflated:
A deflated cuff can lead to air leakage around the endotracheal tube but is not the primary cause of increased airway resistance seen with a high-pressure alarm. It may cause a low-pressure alarm if cuff pressure is monitored.

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Correct Answer is C

Explanation

A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.

B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.

C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.

D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.

A. integrity of the dressing B. Need for suctioning C. Patency of the intravenous line D. Level of pain

Correct Answer is B

Explanation

A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.

B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.

C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.

D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.

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A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

Correct Answer is C

Explanation

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client’s care?

Correct Answer is B

Explanation

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