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?
Tighten the tubing connections.
Request insertion of a tracheostomy tube.
Suction the client's airway.
Look for a leak in the tube's cuff.
The Correct Answer is C
Choice A rationale:
Tightening the tubing connections may be necessary if there is a leak in the ventilator system, but it does not address the high-pressure alarm issue. The nurse needs to address the immediate alarm situation first.
Choice B rationale:
Requesting insertion of a tracheostomy tube is not the appropriate action for a high-pressure alarm on the ventilator. Tracheostomy tube insertion is a significant procedure that is not indicated solely based on a high-pressure alarm.
Choice C rationale:
Suctioning the client's airway is the correct action for a high-pressure alarm on the ventilator. The alarm indicates an obstruction in the airway, and suctioning can help clear any secretions or blockages, allowing the client to breathe more effectively.
Choice D rationale:
Looking for a leak in the tube's cuff may be necessary if the high-pressure alarm persists after suctioning and checking connections. Identifying and repairing any leaks can prevent further issues with ventilation. However, immediate action should be taken to clear the airway first, as indicated by suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.
Choice B rationale:
Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.
Choice C rationale:
Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.
Choice D rationale:
Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.
Correct Answer is B
Explanation
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.