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.

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.

- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

A. Suggest that the client attend adult day care three times per week. B. Review assisted living accommodations with the client. C. Discuss a long-term care referral for the client with the provider. D. Instruct the client about the use of telehealth services.

Correct Answer is D

Explanation

Choice A rationale:

Suggesting that the client attend adult day care three times per week is incorrect. While social interaction is essential for the elderly, it does not address the specific needs of a client with type 2 diabetes mellitus. Moreover, attending adult day care may not necessarily promote diabetes management.

Choice B rationale:

Reviewing assisted living accommodations with the client is incorrect. Assisted living facilities might be suitable for some elderly individuals, but in this case, the client lives independently. There is no indication in the question stem that the client needs assisted living arrangements at this time.

Choice C rationale:

Discussing a long-term care referral for the client with the provider is incorrect. Long-term care facilities are designed for individuals who require extensive assistance with daily activities. There is no information in the question suggesting that the client's condition has deteriorated to the extent of needing long-term care.

Choice D rationale:

Instructing the client about the use of telehealth services is the correct intervention. Telehealth services, including remote monitoring of blood glucose levels, virtual consultations with healthcare providers, and medication management, can enhance diabetes management for elderly individuals living independently in rural areas. Telehealth provides access to healthcare professionals without the need for frequent travel, addressing the challenges faced by individuals residing in remote areas.

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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?

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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?