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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching a client insulin injection technique.
Licensed practical nurses (LPNs) are trained to provide direct patient care, including the administration of medications and patient education. Teaching a client insulin injection technique falls within the scope of practice for an LPN.
B. Evaluating changes to a client’s pressure ulcer:
Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.
C. Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.
D. Scheduling a diagnostic study for a client:
The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.
Correct Answer is C
Explanation
A. Glucagon:
Glucagon is not used as an antidote for heparin overdose. It is typically used to treat severe hypoglycemia.
B. Vitamin K:
Vitamin K is the antidote for warfarin, another anticoagulant, but it is not effective for reversing the effects of heparin.
C. Protamine
Protamine is the specific antidote for heparin. It acts by binding to heparin, neutralizing its anticoagulant effects. It is important to note that the administration of protamine should be done carefully, and the dosage must be based on the amount of heparin the patient has received.
D. Calcium:
Calcium is not an antidote for heparin. It is more relevant in cases of calcium channel blocker toxicity or hypocalcemia.
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