A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Suction the client's airway.

Empty water from the client's ventilator tubing.

Increase the client's ventilator flow rate.

Evaluate the client for a cuff leak.

Answer and Explanation

The Correct Answer is D

D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.

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Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

A. Chlorpromazine B. Dobutamine C. Mannitol D. Propranolol

Correct Answer is C

Explanation

C. Mannitol is a osmotic diuretic that is commonly used in the management of increased intracranial pressure (ICP) following a head injury. It works by drawing fluid out of brain tissue and into the bloodstream, thereby reducing cerebral edema and lowering ICP.
A. Chlorpromazine is an antipsychotic medication that does not have direct effects on reducing ICP and is not commonly used in this clinical scenario.
B. Dobutamine is a medication primarily used for increasing cardiac output in patients with heart failure or shock.
D. Propranolol is a beta-blocker medication commonly used to treat conditions such as hypertension, angina, and certain cardiac arrhythmias.

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