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 B

Explanation

A. "I can expect my eyelids to be bruised after this procedure." – Bruising of the eyelids is not a typical postoperative effect of cataract surgery. The procedure is minimally invasive and does not cause significant trauma to surrounding tissues.

B. "I know the provider will replace the lens in my eyes during this procedure." – This is the correct statement. Cataract surgery involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore vision.

C. "I will see dark spots in my vision after this procedure." – Visual disturbances such as dark spots or floaters are not expected. Some clients may experience mild blurriness, but this should improve as the eye heals.

D. "I will receive general anesthesia for this procedure." – Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia. The client remains awake but does not feel pain.

A. "Lie down for 30 min after meals." B. "Eat a high-fat snack at bedtime." C. "Sip carbonated beverages throughout the day." D. "Drink hot herbal tea to relieve symptoms."

Correct Answer is C

Explanation

A. Lying down after meals increases reflux by allowing stomach contents to flow back into the esophagus.

B. High-fat foods delay gastric emptying, worsening heartburn.

C. Carbonated beverages may help neutralize stomach acid and provide symptom relief when sipped in moderation.

D. Hot herbal tea can relax the lower esophageal sphincter, exacerbating reflux.

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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

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