A newly licensed nurse is caring for a mechanically ventilated client in the intensive care unit. The high pressure alarm becomes triggered. Which of the following interventions is appropriate for this alarm?
Lower the sedation dose on the intravenous pump
Turn off the alarm's volume to promote a therapeutic environment
Tighten connections from endotracheal tube to the ventilator
Suction the client's endotracheal airway
The Correct Answer is D
A. Lowering the sedation dose on the intravenous pump is inappropriate because reducing sedation may cause the client to become more awake and agitated, leading to increased coughing, movement, and fighting against the ventilator, which can worsen high pressure alarms rather than resolve them.
B. Turning off the alarm's volume to promote a therapeutic environment is dangerous and should never be done. Alarm systems are critical safety features that alert nurses to life-threatening problems such as airway obstruction, ventilator disconnection, or high pressures, and silencing them risks patient harm.
C. Tightening connections from endotracheal tube to the ventilator is typically a response for low-pressure alarms indicating disconnection or leak, not high pressure alarms. High pressure alarms signal increased airway resistance or decreased lung compliance rather than loose connections.
D. Suctioning the client's endotracheal airway is appropriate because high pressure alarms often result from secretions blocking the airway. Suctioning removes these obstructions, improves airflow, and decreases resistance within the endotracheal tube, effectively addressing one of the most common causes of high pressure alarms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respiratory alkalosis, uncompensated would show an elevated pH with a decreased PaCO₂, typically due to hyperventilation. However, the PaCO₂ here is normal, and the elevated bicarbonate indicates that the cause of alkalosis is metabolic, not respiratory, making this an incorrect choice.
B. Metabolic alkalosis, uncompensated is the correct answer because the pH is elevated above 7.45, and the bicarbonate level is also elevated at 31 mEq/L. The PaCO₂ remains within the normal range, indicating that there has been no respiratory compensation yet, thus fitting the pattern of uncompensated metabolic alkalosis.
C. Respiratory acidosis, partially compensated would present with a low pH and a high PaCO₂, which is not the case here. The client’s pH is elevated and PaCO₂ is normal, eliminating respiratory acidosis from consideration.
D. Metabolic acidosis, partially compensated would show a low pH with a low bicarbonate level, typically accompanied by a compensatory decrease in PaCO₂. This client has an elevated pH and elevated bicarbonate, ruling out metabolic acidosis as a possibility.
Correct Answer is A
Explanation
A. Bag-valve-mask device should always be at the bedside when administering a neuromuscular blocking agent because these medications cause paralysis of respiratory muscles, including the diaphragm. The client will require manual ventilation support if mechanical ventilation fails or is delayed to ensure adequate oxygenation.
B. Client's personal phone is not a priority item for immediate bedside safety. Although maintaining communication with loved ones is important for emotional well-being, the critical concern with neuromuscular blockade is airway management and respiratory support.
C. Urinary catheter insertion tray may eventually be necessary if the client is immobilized for a prolonged period, but it is not an immediate requirement when administering a paralytic agent. The priority remains ensuring airway patency and respiratory support.
D. Central venous catheterization tray is not required solely for administering a neuromuscular blocking agent. While some critically ill patients need central access, peripheral intravenous access is often sufficient for delivering the medication itself.
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