A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

The patient may need suctioning

The patient extubated himself

The ventilator tubing may be disconnected.

The cuff at the end of the endotracheal tube is deflated.

Answer and Explanation

The Correct Answer is A

A. The patient may need suctioning:
A high-pressure alarm indicates increased resistance to airflow, which could be caused by secretions or mucus in the airways. Suctioning is the appropriate intervention to clear the airways of excess secretions, reducing airway resistance and preventing the high-pressure alarm.

B. The patient extubated himself:
If the patient extubates himself (removes the endotracheal tube), this may result in a low-pressure alarm, not a high-pressure alarm. The low-pressure alarm is triggered when there is a loss of pressure within the ventilator circuit due to disconnection or extubation.

C. The ventilator tubing may be disconnected:
If the ventilator tubing is disconnected, it is more likely to trigger a low-pressure alarm, indicating a loss of pressure in the ventilator circuit. This is not the primary cause of increased resistance seen with a high-pressure alarm.

D. The cuff at the end of the endotracheal tube is deflated:
A deflated cuff can lead to air leakage around the endotracheal tube but is not the primary cause of increased airway resistance seen with a high-pressure alarm. It may cause a low-pressure alarm if cuff pressure is monitored.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. A client who is taking a thiazide diuretic:
Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.

B. A client who is vomiting:
Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.

C. A client who has diarrhea.
Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.

D. A client who is having an acute anxiety attack:
Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.

Correct Answer is ["100"]

Explanation

Clindamycin is an antibiotic that can treat infections caused by staphylococci bacteria. It can be given by intermittent IV bolus, which means injecting the drug into a vein over a short period of time. To calculate the infusion rate for clindamycin, we need to use the formula:

Infusion rate (ml/hr) = Volume (ml) / Time (hr)

In this case, the volume is 50 ml and the time is 0.5 hr (30 min). Plugging these values into the formula, we get:

Infusion rate (ml/hr) = 50 ml / 0.5 hr

Infusion rate (ml/hr) = 100 ml/hr

Therefore, the nurse should set the IV pump to deliver 100 ml/hr of clindamycin.

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A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that a clients is at risk for metabolic acidosis?

Correct Answer is C

Explanation

Correct Answer is ["100"]

Explanation

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