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. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.

B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.

C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.

D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.

A. Potassium level B. Thyroid function tests C. Uric acid level D. Liver function tests

Correct Answer is D

Explanation

A. Potassium level – Valproic acid does not significantly affect potassium levels, so this is not a necessary baseline test.

B. Thyroid function tests – Valproic acid is not known to significantly impact thyroid function, making this an unnecessary test.

C. Uric acid level – Uric acid levels are more relevant for conditions like gout, and valproic acid does not typically cause hyperuricemia.

D. Liver function tests – This is the correct answer because valproic acid is metabolized in the liver and can cause hepatotoxicity. Baseline liver function tests (LFTs) should be reviewed before starting the medication to assess liver health.

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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 planning care for a client who is undergoing alcohol withdrawal and is receiving diazepam. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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