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 C
Explanation
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.
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.
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