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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Teaching a client insulin injection technique.
Licensed practical nurses (LPNs) are trained to provide direct patient care, including the administration of medications and patient education. Teaching a client insulin injection technique falls within the scope of practice for an LPN.

B. Evaluating changes to a client’s pressure ulcer:
Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.

C. Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.

D. Scheduling a diagnostic study for a client:
The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.

A. Fluctuation of the fluid level within the water seal chamber B. Equal amounts of fluid drainage in each collection chamber C. Continuous bubbling within the water seal chamber D. Absence of fluid in the drainage tubing

Correct Answer is A

Explanation

A. Fluctuation of the fluid level within the water seal chamber
Fluctuation of the fluid level within the water seal chamber indicates that the chest tube is functioning properly. This fluctuation is a normal finding and reflects the movement of air in and out of the pleural space during the respiratory cycle. As the patient inhales, the fluid level drops, and as they exhale, it rises.

B. Equal amounts of fluid drainage in each collection chamber:
Equal amounts of drainage may suggest a problem with the drainage system or that the chest tube is not effectively draining air or fluid from the pleural space.

C. Continuous bubbling within the water seal chamber:
Continuous bubbling in the water seal chamber may indicate an air leak, which is not a normal finding. It should be investigated further.

D. Absence of fluid in the drainage tubing:
The absence of fluid in the drainage tubing may suggest that the chest tube is not effectively draining fluid from the pleural space or that there is a blockage in the system. It requires assessment and intervention.

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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

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Correct Answer is A

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