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 D
Explanation
- A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.
- B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.
- C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.
- D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.
Correct Answer is ["18"]
Explanation
The client weighs 198 lb, which is equivalent to (198 ÷ 2.2 = 90kg.
Therefore, the amount of mannitol for the test dose is 0.2 g/kg x 90 kg = 18 g. The nurse should administer 18 g of mannitol IV bolus over 5 min as a test dose to the client who has severe oliguria.
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