While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Suction the client's airway.

Look for a leak in the tube's cuff

Tighten the tubing connections.

Request insertion of a tracheostomy tube

Answer and Explanation

The Correct Answer is A

A. Suction the client's airway – This is the correct answer. A high-pressure alarm on a ventilator usually indicates an obstruction, such as mucus plugging or secretions in the airway. Suctioning helps clear the obstruction.

B. Look for a leak in the tube's cuff – A leak would trigger a low-pressure alarm, not a high-pressure alarm.

C. Tighten the tubing connections – Loose connections generally cause low-pressure alarms rather than high-pressure alarms.

D. Request insertion of a tracheostomy tube – This may be necessary for long-term ventilation, but it is not the immediate intervention for a high-pressure alarm.

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Correct Answer is C

Explanation

A. Weight gain is a sign of hypothyroidism, not thyrotoxicosis.

B. Bradycardia is associated with hypothyroidism, whereas thyrotoxicosis causes tachycardia.

C. This is the correct answer. Fever is a symptom of thyrotoxicosis, which results from excessive thyroid hormone levels, leading to hypermetabolism. Other signs include tachycardia, anxiety, heat intolerance, and weight loss.

D. Drowsiness is more commonly associated with hypothyroidism.

A. Dry mouth B. Constipation C. Insomnia D. Excessive sweating

Correct Answer is D

Explanation

A. Dry mouth is a common side effect but not a sign of serotonin syndrome.

B. Constipation is another possible side effect but is not an emergency.

C. Insomnia can occur but does not indicate serotonin syndrome.

D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.

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While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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