A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

Check for a disconnection in the ventilator tubing.

Assess the ET for a cuff leak.

Verify the placement of the ET

Check for a kink in the ventilator tubing.

Suction the ET to remove secretions

Answer and Explanation

Correct Answer : D,E

Rationale:

A. Check for a disconnection in the ventilator tubing: A disconnection typically causes a low-pressure alarm, not an increase in peak airway pressure, and would not be the appropriate first response in this case.

B. Assess the ET for a cuff leak: A cuff leak would decrease airway pressure, potentially causing a low-pressure alarm. It is not associated with increased peak airway pressure alarms.

C. Verify the placement of the ET: ET tube misplacement can lead to ventilation issues, but it does not directly cause increased peak pressures unless malposition leads to obstruction, which would be less common.

D. Check for a kink in the ventilator tubing: A kink or obstruction in the tubing increases airway resistance and can cause high peak airway pressure alarms. Resolving the kink can restore normal pressure.

E. Suction the ET to remove secretions: Mucus plugging or secretion buildup increases resistance in the airway, raising peak pressures. Suctioning helps alleviate the obstruction and reduce alarm triggers.

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Correct Answer is B

Explanation

Rationale:

A. Increased hemoglobin: Elevated hemoglobin levels are generally associated with dehydration, high altitude, or chronic hypoxia, but they are not specific indicators of infection. Hemoglobin does not provide direct evidence of a bacterial process.

B. Increased absolute neutrophils: Neutrophils are the primary white blood cells involved in fighting bacterial infections. An elevated absolute neutrophil count suggests an acute bacterial infection or an inflammatory response caused by bacterial pathogens.

C. Decreased C-reactive protein: CRP is a marker of inflammation, often elevated during bacterial infections. A decreased CRP level makes bacterial infection less likely and is not consistent with the inflammatory response usually seen in such cases.

D. Decreased platelets: Low platelet counts (thrombocytopenia) can result from viral infections, autoimmune diseases, or bone marrow disorders. While they may be altered in sepsis, they are not a reliable or primary marker of a typical bacterial infection.

A. Limit visitors to 30 min per day. B. Instruct visitors who are pregnant to remain 3 feet from the client. C. Wear a lead apron when providing care. D. Place the client in a semi-private room. E. Close the door to the client's room.

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

Explanation

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help minimize radiation exposure to visitors. Short visits reduce the cumulative dose received, which is especially important for non-staff individuals who are not regularly monitored for radiation exposure.

B. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant individuals should avoid close contact with radiation sources due to fetal sensitivity. Maintaining a 3-foot distance helps reduce exposure to scattered radiation from the sealed implant.

C. Wear a lead apron when providing care: A lead apron provides protection against scatter radiation, particularly during direct, prolonged care. Nurses should also stand as far away from the source as possible and work efficiently to limit time near the implant.

D. Place the client in a semi-private room: Clients with sealed radiation implants require a private room to protect others from radiation exposure. A semi-private room would place another patient at unnecessary risk and violates radiation safety protocols.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the room, thereby protecting other individuals in the surrounding area. It is a standard precaution for clients receiving internal radiation therapy.

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A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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

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