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 E
Explanation
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
Correct Answer is ["B","C","D","E","F"]
Explanation
The normal physiological changes of aging that the nurse can expect in an older adult during a musculoskeletal assessment include:
● Widened Gait: With age, there can be a natural widening of the gait due to changes in balance and stability.
● Kyphosis: Kyphosis refers to an increased curvature of the thoracic spine, commonly known as a "hunchback" appearance, which can occur due to changes in the vertebral bones and intervertebral discs.
● Slowed movement: Older adults may experience a natural decline in their movement speed due to changes in muscle strength, coordination, and reaction time. ● Muscle atrophy: Age-related muscle atrophy, or loss of muscle mass, can occur, particularly if the older adult leads a sedentary lifestyle or has other underlying health conditions.
● Decreased joint ROM (Range of Motion): Older adults may experience a gradual decrease in joint flexibility and range of motion due to changes in the joints, ligaments, and surrounding tissues. This can affect their ability to move joints fully.
It's important to note that while some older adults may develop arthritis, it is not considered a normal physiological change of aging. Arthritis refers to the inflammation and degeneration of joints, which can occur due to various factors, including age, genetics, and lifestyle.
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