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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
To calculate the milliliters per hour (mL/hr) for the IV infusion, you divide the total volume (in milliliters) by the total time (in hours).
In this case, the total volume is 1 liter, which is equal to 1000 milliliters, and the total time is 6 hours.
So, you divide 1000 mL by 6 hours:
1000 mL / 6 hours = 166.67 mL/hr
Rounding off, the nurse will program the IV infusion device to infuse at approximately 167 mL/hr.
Correct Answer is ["A","C","D"]
Explanation
Each of your meals should contain about 10 tablespoons of food: After gastric bypass surgery, the stomach's size is reduced, and the patient's capacity to consume large quantities of food is limited. It is important to educate the patient about appropriate portion sizes to avoid overeating and potential complications.
Be certain to stay hydrated by drinking water: Hydration is crucial after gastric bypass surgery. Patients should be advised to drink enough water throughout the day to prevent dehydration and ensure proper bodily function.
Solid food can be introduced back into the diet in a week: Following gastric bypass surgery, the diet is initially limited to liquid and pureed foods. Gradually, solid foods can be reintroduced into the diet over time, typically after a week or as directed by the surgeon. This information is important for the patient to understand the progression of their diet post-surgery. You are likely to have little urine output for the first few weeks: This statement is not true and may cause unnecessary concern for the patient. Urine output should not be affected by gastric bypass surgery unless there are other complications.
Report any back, shoulder, or abdominal pain to the surgeon: While it is important to report any significant pain or discomfort to the surgeon, including back, shoulder, or abdominal pain, this is not specific to discharge teaching for gastric bypass surgery. Pain management and reporting should be covered during the post-operative care instructions, but it is not limited to discharge teaching alone.
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