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: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.
- D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.
- C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.
- B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.
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.
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