A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

Rationale:

A. Check for a disconnection in the ventilator tubing: A disconnection typically causes a low-pressure alarm, not an increase in peak airway pressure, and would not be the appropriate first response in this case.

B. Assess the ET for a cuff leak: A cuff leak would decrease airway pressure, potentially causing a low-pressure alarm. It is not associated with increased peak airway pressure alarms.

C. Verify the placement of the ET: ET tube misplacement can lead to ventilation issues, but it does not directly cause increased peak pressures unless malposition leads to obstruction, which would be less common.

D. Check for a kink in the ventilator tubing: A kink or obstruction in the tubing increases airway resistance and can cause high peak airway pressure alarms. Resolving the kink can restore normal pressure.

E. Suction the ET to remove secretions: Mucus plugging or secretion buildup increases resistance in the airway, raising peak pressures. Suctioning helps alleviate the obstruction and reduce alarm triggers.

Rationale:

A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.

B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.

C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.