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)
Suction the ET to remove secretions.
Verify the placement of the ET.
Check for kinks in the ventilator tubing.
Administer a bronchodilator.
Increase the tidal volume.
Correct Answer : A,B,C,D
Choice A reason: Suctioning the ET removes secretions obstructing airflow, increasing peak airway pressure. Mucus buildup narrows the airway, triggering alarms. Clearing secretions restores patency, reduces pressure, and prevents complications like atelectasis or hypoxia, critical for effective ventilation in mechanically ventilated clients.
Choice B reason: Verifying ET placement ensures the tube is in the trachea. Misplacement, like esophageal intubation, increases airway resistance, elevating peak pressure. Confirmation via capnography or X-ray prevents hypoxia, ensuring proper ventilation and safety in clients on mechanical ventilators.
Choice C reason: Checking for kinks in ventilator tubing addresses mechanical obstructions raising peak airway pressure. Kinks restrict airflow, triggering alarms. Straightening tubing restores normal gas delivery, reducing resistance and maintaining effective ventilation, preventing hypoxia in mechanically ventilated clients.
Choice D reason: Administering a bronchodilator relieves bronchospasm, a common cause of high peak airway pressure. Bronchoconstriction narrows airways, increasing resistance. Bronchodilators relax smooth muscles, improving airflow and reducing pressure, addressing reversible causes like asthma in ventilated clients.
Choice E reason: Increasing tidal volume exacerbates high peak airway pressure, risking barotrauma or lung injury by forcing air against resistance. Addressing underlying causes like secretions or bronchospasm is safer, as higher volumes do not resolve the root issue, potentially worsening outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Using a mechanical lift for a 136 kg client unable to assist ensures safety for both client and nurse. Lifts prevent injury by supporting the client’s weight, reducing strain on staff. This adheres to safe patient handling guidelines, minimizing risks of falls or musculoskeletal injuries during transfer.
Choice B reason: Asking another nurse to assist is insufficient for a 136 kg client unable to help, as manual lifting risks injury to staff and client. Mechanical lifts are required for heavy or non-assistive clients to ensure safety, making this option inadequate and unsafe for the transfer scenario described.
Choice C reason: Positioning the client upright before transfer is impractical for a non-assistive client weighing 136 kg, as it requires significant manual effort and risks injury. Mechanical lifts are needed to safely move such clients, ensuring stability and preventing falls, making this action inappropriate for the transfer.
Choice D reason: A sliding board is unsuitable for a 136 kg client unable to assist, as it requires some patient cooperation and strength. It risks injury to staff and client due to the client’s weight and inability to participate. Mechanical lifts are the safer, recommended method for this transfer.
Correct Answer is D
Explanation
Choice A reason: Adding salt to season foods can irritate oral sores in AIDS patients, often caused by candidiasis or herpes. Salt exacerbates pain and delays healing, making this instruction harmful and inappropriate for managing oral discomfort in this population.
Choice B reason: Rinsing with alcohol-based mouthwash worsens oral soreness, as alcohol irritates mucosal lesions common in AIDS. Non-alcohol, antiseptic, or saline rinses are preferred to promote comfort and healing, making this instruction incorrect and potentially painful.
Choice C reason: Eating hot foods can aggravate oral sores, increasing pain and delaying healing in AIDS patients with mucosal damage. Lukewarm or cool foods are better tolerated, making this instruction inappropriate and counterproductive for managing the client’s symptoms.
Choice D reason: Using ice chips numbs the mouth, reducing pain from oral sores during eating for AIDS patients. This non-invasive, soothing intervention is safe and effective, aligning with comfort-focused care for mucosal lesions, making it the correct instruction.
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