The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?

Notify the health care provider

Insert an oral airway to prevent the client from biting the tube

Suction the client and reset the alarm

Disconnect the client from the ventilator and use a manual resuscitation bag

Answer and Explanation

The Correct Answer is D

A. Notify the healthcare provider: While notifying the healthcare provider may eventually be necessary, the first priority is to ensure the client's airway is protected and they are receiving adequate ventilation. The provider can be notified after immediate interventions have been made to stabilize the patient.

B. Insert an oral airway to prevent the client from biting the tube: Inserting an oral airway may be necessary if the client is biting the endotracheal tube, but this is unlikely the first action needed in response to a low-pressure alarm. If the client is not biting the tube, this action will not address the potential causes of the low-pressure alarm, such as a disconnection, leak, or circuit issue.

C. Suction the client and reset the alarm: While suctioning is an important intervention if secretions are the cause of ventilation issues, it is not the first action when the source of the low-pressure alarm is unclear. If a disconnection or leak is the issue, suctioning will not resolve the problem, and the nurse risks delaying appropriate action to address the source of the alarm. The priority is ensuring the client’s ventilation is not compromised, which is best accomplished by using a manual resuscitation bag until the problem is identified and corrected.

D. Disconnect the client from the ventilator and use a manual resuscitation bag: If the source of the low-pressure alarm cannot be identified after checking the client and the ventilator, the first priority is to ensure that the client continues to receive adequate ventilation. Disconnecting the client from the ventilator and using a manual resuscitation bag (Ambu bag) allows for immediate support of the patient's ventilation while the nurse investigates the cause of the alarm. This ensures the client's oxygenation and ventilation needs are met until the problem is resolved. It is critical to address any potential loss of positive pressure or leaks in the ventilator system promptly to avoid respiratory distress or failure.

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Correct Answer is C

Explanation

A. Dextromethorphan 10 mg PO q 4 hr: Dextromethorphan is a cough suppressant, and while it may be useful for controlling a dry, non-productive cough, it is not appropriate for ineffective airway clearance in pneumonia. In fact, suppressing the cough in pneumonia could prevent the patient from clearing mucus from the airways, exacerbating the problem. It is more appropriate for a client who has a dry cough without significant mucus production.

B. Cromolyn MDI 2 puffs daily: Cromolyn is a mast cell stabilizer used for the prevention of asthma and allergy symptoms, and it is not typically used for treating pneumonia or ineffective airway clearance. It works by preventing the release of inflammatory mediators in response to allergens, but it does not address the issue of clearing mucus in the airways during a bacterial infection like pneumonia.

C. Guaifenesin 200 mg PO q 4 hr: Guaifenesin is an expectorant that helps loosen and thin mucus in the airways, making it easier for the client to cough up and clear secretions. This is the most appropriate medication for addressing ineffective airway clearance in a client with pneumonia, as the goal is to facilitate the removal of mucus and improve respiratory function. Guaifenesin does not suppress the cough reflex but instead promotes productive coughing, which is essential for clearing the airways during a respiratory infection like pneumonia.

D. Methylprednisolone 30 mg IV BID: Methylprednisolone is a corticosteroid used to reduce inflammation and control severe allergic or inflammatory conditions. While corticosteroids may be used in certain cases of pneumonia (e.g., in cases of significant inflammation or an underlying condition like COPD), they are not the first-line treatment for ineffective airway clearance. The priority in this case is to promote mucus clearance, which is better addressed by guaifenesin.

A. hyperglycemia B. Urinary retention C. Respiratory failure D. Hypertension

Correct Answer is C

Explanation

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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