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 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.
Correct Answer is A
Explanation
A. This is the correct answer. Gentle hand exercises, such as ball squeezing, help promote circulation and prevent lymphedema in the affected arm.
B. Avoiding use of the affected arm for eating is incorrect. Gradual movement is encouraged to prevent stiffness and maintain mobility.
C. Using deodorant under the affected arm is not recommended until healing is complete, as it may cause irritation or infection.
D. A bra with wire support should be avoided initially due to discomfort and potential interference with healing.
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