The nurse is caring for a client on a ventilator from complications of pneumonia. The nurse observes the low-pressure ventilator alarm and a pulse oximetry reading of 85%. What should be the nurse's first action?

Suction the client's endotracheal tube

Add air to the pilot balloon on the endotracheal tube

Providing ventilation with a bag-valve-mask device

Place a bit block in the client's mouth

Answer and Explanation

The Correct Answer is C

A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.

Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.

Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.

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Correct Answer is D

Explanation

The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.

While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.

Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.

A. Relax smooth muscles of the bronchial airway. B. Prevent Infection. C. Suppress the cough. D. Promote Expectoration.

Correct Answer is A

Explanation

Aminophylline is a bronchodilator that belongs to the xanthine derivative class of medications. It works by relaxing the smooth muscles surrounding the bronchial airways, which leads to bronchodilation. By dilating the airways, aminophylline helps to relieve bronchospasm, improve airflow, and facilitate easier breathing.

Prevent Infection: Aminophylline is not an antimicrobial medication, and its primary action is not related to preventing or treating infections.

Suppress the cough: While aminophylline may have some antitussive (cough-suppressing) effects, its primary action is bronchodilation rather than directly suppressing the cough reflex. Promote Expectoration: Aminophylline is not primarily indicated for promoting expectoration (bringing up mucus). It mainly focuses on bronchodilation to improve airflow and relieve bronchospasm.

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The nurse is caring for a client on a ventilator from complications of pneumonia. The nurse observes the low-pressure ventilator alarm and a pulse oximetry reading of 85%. What should be the nurse's first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

Correct Answer is D

Explanation

Aminophylline is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to:

Correct Answer is A

Explanation

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

The nurse receives an order to draw a peak level on a patient prescribed Gentamicin via Intravenous (IV) infusion. When is the best time for the nurse to draw this peak level?

Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

The nurse is delegating ambulation for a client to an experienced Patient Care Technician (PCT).Which teaching will the nurse provide to the PCT? (Select all that apply.)

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