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. Prednisone should be taken with food to reduce gastrointestinal irritation.
B. Aspirin increases the risk of GI bleeding when taken with prednisone.
C. Prednisone doses should be increased, not reduced, during stress to prevent adrenal insufficiency.
D. This is the correct answer. Weight-bearing exercises like walking help reduce the risk of osteoporosis, a side effect of long-term prednisone use.
Correct Answer is C
Explanation
A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.
B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.
C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.
D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.
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