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 B

Explanation

Answer: B

Rationale:

A) Activate the fire alarm system:

While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.

B) Evacuate clients from the area:

Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.

C) Obtain and use a fire extinguisher:

Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.

D) Close the doors and windows on the unit:

Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.

A. The client's heart rate increases by 10/min. B. The client's systolic blood pressure decreases by 25 mm Hg. C. The client's diastolic blood pressure increases by 10 mm Hg. D. The client reports heart palpitations.

Correct Answer is B

Explanation

A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.

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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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