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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

A. Remove the restraints immediately. B. Encourage the client to attend a group therapy session. C. Continue to monitor the client every 15 minutes. D. Administer a sedative to maintain calm behavior.

Correct Answer is C

Explanation

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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