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?

Request insertion of a tracheostomy tube.

Suction the client's airway.

Tighten the tubing connections.

Look for a leak in the tube's cuff.

Answer and Explanation

The Correct Answer is B

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.

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Correct Answer is A

Explanation

A. Report sudden, persistent headaches: Sudden, persistent headaches can indicate a sickle cell crisis or complications such as stroke. Prompt reporting of these symptoms allows for timely intervention and management of potential complications.
B. Avoid meningococcal immunizations: Immunizations, including meningococcal vaccines, are essential for individuals with sickle cell anemia because they are at increased risk of infections, including those caused by encapsulated bacteria like Neisseria meningitidis. Immunizations help prevent serious infections and their complications.
C. Apply cold compresses to painful areas: Cold compresses are not recommended for individuals with sickle cell anemia. Heat therapy is typically used to alleviate pain associated with vaso-occlusive crises, which are common in sickle cell disease. Heat helps relax muscles and improve blood flow to the affected area, reducing pain and promoting healing.
D. Restrict fluid intake during times of stress: Individuals with sickle cell anemia should maintain adequate hydration at all times, especially during periods of stress or illness. Dehydration can exacerbate sickling of red blood cells and increase the risk of vaso-occlusive crises. Therefore, fluid intake should be encouraged, and restrictions should be avoided unless specifically advised by a healthcare provider.

A. Diaphoresis B. Fever C. Polyuria D. Diarrhea

Correct Answer is B

Explanation

A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.

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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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