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 C
Explanation
A. Prepare to administer a sedative:
Administering a sedative is not the priority in this situation. The client is experiencing shortness of breath, tachycardia, and hypoxemia, indicating a respiratory issue that needs immediate attention. Sedation can further depress the respiratory drive and exacerbate the hypoxemia.
B. Assess for indications of pulmonary embolism:
While the client's symptoms could be related to a pulmonary embolism, the priority at this moment is to address the immediate respiratory distress. Administering oxygen is crucial before further diagnostic assessments can take place. Once the client is stabilized, additional assessments can be performed to explore the cause of the symptoms.
C. Administer oxygen via face mask:
This is the correct and priority intervention. The client is hypoxic (SaO2 86%) with a low PaO2 and high respiratory rate. Administering oxygen via a face mask aims to improve oxygenation and relieve the hypoxemia associated with the respiratory distress.
D. Prepare for mechanical ventilation:
Mechanical ventilation may be considered if the client's respiratory distress is severe and not responsive to oxygen therapy. However, the immediate step is to administer oxygen via a face mask. If the client's condition does not improve with oxygen therapy, mechanical ventilation may be the next step.
Correct Answer is D
Explanation
A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.
B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.
C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.
D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.
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