A nurse is making her 4-hour rounds on her patient who is on a ventilator. Up until this time the patient has been doing well with no complications but now alarms are sounding. The nurse knows that alarms should never be ignored. On closer inspection, he/she notices that it is the high-pressure alarm that is sounding. Select the following that would signify why the high-pressure alarm would be sounding. (Select all that apply)
A kink in the tubing
A leak in the ventilator circuit prevents breath from being delivered
An increased amount of secretions or a mucus plug is in the airways
RT is changing the ventilator tubing/circuit
The patient stops spontaneous breathing in the SIMV or CPAP mode or on pressure support ventilation
Correct Answer : A,C
Rationale:
A. A kink or obstruction in the ventilator tubing increases resistance to airflow. The ventilator is pressure-triggered and senses that it must generate higher pressure than normal to deliver the set tidal volume. This triggers the high-pressure alarm. Nurses should inspect the tubing immediately, straighten any kinks, and ensure the circuit is free from obstruction.
B. A leak causes a loss of delivered volume or pressure, which usually triggers a low-pressure alarm rather than a high-pressure alarm. Leaks allow air to escape, so the ventilator cannot build the necessary pressure to deliver a full breath.
C. Secretions or mucus plugs obstruct airflow in the endotracheal or tracheostomy tube, making it harder for the ventilator to push air into the lungs. This obstruction increases airway pressure, resulting in a high-pressure alarm. Nurses should assess lung sounds, suction the airway if needed, and ensure proper humidification to prevent thick secretions.
D. Changing the circuit may temporarily trigger an alarm, but this is usually brief and procedural, not a physiologic cause of a high-pressure alarm. Once the circuit is connected properly, the alarm should resolve.
E. In modes that rely on spontaneous breathing, apnea or lack of patient effort usually triggers an apnea or low tidal volume alarm, not a high-pressure alarm. The high-pressure alarm reflects resistance or obstruction, not absence of breathing effort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Advanced age is incorrect because, while older patients are at higher risk for acute kidney injury (AKI) due to decreased renal reserve, age itself is not the most common cause of AKI in critically ill patients. It is a predisposing factor, not a direct cause.
B. Medications is incorrect because nephrotoxic drugs (like aminoglycosides, NSAIDs, or contrast agents) can cause AKI, but in critically ill patients, medications are a less frequent primary cause compared to systemic insults like sepsis.
C. Sepsis is correct because sepsis is the leading cause of AKI in critically ill patients. The systemic infection and associated inflammatory response, hypotension, and hypoperfusion lead to ischemic injury of the kidneys. Sepsis-induced AKI often involves both prerenal factors (low perfusion) and intrinsic renal injury (acute tubular necrosis). Early recognition and aggressive management of sepsis are critical to prevent progression of AKI.
D. Fluid overload is incorrect because fluid overload is a complication of AKI rather than a cause. AKI can lead to reduced urine output, causing fluid accumulation, but it is not the initiating factor in most cases.
Correct Answer is A
Explanation
Rationale:
A. Acute stroke is correct because PCI is a procedure designed to restore blood flow in narrowed or blocked coronary arteries in the heart. An acute stroke involves cerebral arteries, not coronary arteries. Treatment for stroke may include thrombolytics, mechanical thrombectomy, or supportive care, but PCI is not indicated. Performing PCI in a stroke patient would not address the underlying problem and could increase risks of complications, including bleeding.
B. Chronic stable angina unresponsive to medical therapy is incorrect because patients with persistent angina despite optimal medical management, such as nitrates, beta-blockers, or calcium channel blockers, may benefit from PCI. PCI improves coronary blood flow, reduces symptoms, and enhances quality of life.
C. Multi-vessel coronary artery disease in a patient with heart failure is incorrect because PCI can be indicated in patients with multi-vessel disease, especially if surgical revascularization (CABG) is high-risk or contraindicated. It may help improve myocardial perfusion, reduce ischemia, and potentially improve heart function in selected patients.
D. High-risk unstable angina is incorrect because patients with unstable angina and high-risk features, such as ongoing chest pain, ST-segment changes, or elevated troponins, require urgent PCI. PCI can prevent progression to myocardial infarction and improve survival.
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