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 B
Explanation
A. “Check your oxygen equipment once each week.”
Checking the oxygen equipment once a week is insufficient. The equipment should be regularly inspected for safety, including tubing, connections, and the condition of the oxygen concentrator or tank.
B. “Do not adjust the oxygen flow rate.”
The nurse should include in the teaching that the client should not adjust the oxygen flow rate without consulting their healthcare provider. Adjusting the oxygen flow rate without proper guidance can lead to inappropriate oxygen delivery, which may be harmful.
C. “Store unused oxygen tanks horizontally.”
Oxygen tanks should be stored in an upright position to prevent damage to the tank valve. Storing them horizontally can increase the risk of leaks or damage.
D. “Keep wool blankets on your bed.”
Wool blankets and other items that generate static electricity should be avoided near oxygen equipment, as they can increase the risk of fire. The client should be advised to use non-static bedding and clothing.
Correct Answer is C
Explanation
A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.
B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.
C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.
D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.