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 B

Explanation

Pain tolerance refers to the maximum level of pain that an individual can tolerate without significant distress. It is influenced by various factors, including psychological and emotional factors. While emotions such as anger, boredom, and introversion can have an impact on a person's pain perception and experience, sleep plays a significant role in pain tolerance. During sleep, the body is in a state of rest and relaxation, allowing for decreased sensory input and potentially reducing pain perception. Sleep provides an opportunity for the body to repair and heal, which can contribute to improved pain tolerance. Additionally, sleep promotes the release of endogenous opioids, which are natural pain-relieving substances produced by the body.

A. The client has a fever. B. The patient requested that suctioning be performed. C. Crackles and wheezing is heard upon auscultation D. The tracheostomy dressing has a moderate amount of serosanguineous drainage. E. Suction was performed more than (4) hours ago.

Correct Answer is ["C","D","E"]

Explanation

Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.

The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.

Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.

While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.

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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 client is suffering from osteoarthritis in the knees and the nurse is providing care. The nurse is assessing the client's pain level and pain tolerance. Based on the nurse's understanding of pain, the nurse knows that a client's pain tolerance is most likely relieved by which of the following?

Correct Answer is B

Explanation

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

Correct Answer is ["C","D","E"]

Explanation

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