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. Transformational leader:
Transformational leaders are characterized by their ability to inspire and motivate followers to achieve exceptional outcomes. They focus on building relationships, fostering creativity, and encouraging individual and team growth. Transformational leaders are often seen as visionary and charismatic.
B. Situational leader:
Situational leadership is a flexible approach where leaders adjust their style based on the situation and the readiness or maturity of their followers. The leader may use different leadership styles, ranging from directing to delegating, depending on the circumstances.
C. Bureaucratic leader:
Bureaucratic leaders strictly enforce rules and regulations. They rely on established policies and procedures to maintain order and control within the organization. This style is often associated with a more structured and rule-based approach to leadership.
D. Laissez-faire leader:
Laissez-faire leaders adopt a hands-off or delegative approach, providing little guidance or direction to their team members. They allow team members a high degree of autonomy and decision-making authority. While this style can promote creativity and independence, it may lead to a lack of structure and accountability in certain situations.
Correct Answer is C
Explanation
A. Loop the tubing of the chest tube on the client’s bed:
Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.
B. Strip the client’s chest tube every 2 hrs:
Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.
C. Place the chest tube drainage system below the level of the client’s heart:
This is the correct action. Placing the chest tube drainage system below the level of the client's chest allows gravity to assist with drainage and prevents backflow or accumulation of fluids within the chest tube.
D. Tape the connections on the client’s chest tube:
Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.
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