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?

Increase the client's ventilator flow rate.

Empty water from the client's ventilator tubing.

Evaluate the client for a cuff leak.

Suction the client's airway.

Answer and Explanation

The Correct Answer is C

A)   Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B)   Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C)   Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D)   Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

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Correct Answer is D

Explanation

A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.

A. A client who has peritonitis reports generalized abdominal pain. B. A client who has pancreatitis reports pain in the left shoulder. C. A client who has angina reports substernal chest pain. D. A client who is postoperative reports incisional pain.

Correct Answer is B

Explanation

A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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