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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A referral to long-term care is premature since the client lives independently and may not require institutionalized care.
B. Assisted living accommodations are not necessary unless the client struggles with self-care or safety concerns.
C. Adult day care is beneficial for socialization but does not address the primary issue of diabetes management in a rural setting.
D. Telehealth services allow clients in rural areas to consult with healthcare providers remotely, improving access to care, medication management, and education on diabetes self-care.
Correct Answer is B
Explanation
A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.
B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.
C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.
D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.
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