A patient on mechanical ventilation suddenly triggers a high-pressure alarm. Which of the following should the nurse assess first?
The patient’s airway for secretions or kinking
The ventilator’s tubing connections
The humidifier water level
The patient’s urine output in the past hour
The Correct Answer is A
A high-pressure alarm on a mechanical ventilator indicates that airway resistance has increased or there is reduced lung compliance. The nurse’s first action should be to assess the patient’s airway for obstructions such as secretions, kinks in the tube, or biting of the ET tube, as these are the most common and immediately correctable causes.
Rationale for Correct Answer
1. The patient’s airway for secretions or kinking: Obstruction in the airway is the most common cause of a high-pressure alarm. Rapid assessment and intervention, such as suctioning or repositioning the ET tube, can restore ventilation and prevent hypoxia. Immediate patient assessment is priority over equipment checks.
Rationale for Incorrect Answers
2. The ventilator’s tubing connections: Loose or disconnected tubing usually triggers a low-pressure alarm, not high-pressure. While checking equipment is important, it is secondary to assessing the patient.
3. The humidifier water level: Low or high water in the humidifier may affect humidification but is unlikely to trigger a high-pressure alarm.
4. The patient’s urine output in the past hour: Urine output is unrelated to ventilator pressure alarms and is not an immediate concern in this context.
Take-Home Points
- High-pressure alarms usually indicate airway obstruction or decreased lung compliance.
- Immediate assessment of the patient’s airway is the first priority.
- Common interventions include suctioning secretions, repositioning the ET tube, or checking for kinks.
- Equipment and ventilator settings should be evaluated after patient safety is ensured.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Positive end-expiratory pressure (PEEP) improves oxygenation by preventing alveolar collapse, but excessive PEEP increases intrathoracic pressure, which can impair venous return and reduce cardiac output. The earliest and most significant sign of this hemodynamic effect is decreased blood pressure.
Rationale for Correct Answer
1. Decreased blood pressure: Elevated intrathoracic pressure from high PEEP reduces venous return to the heart, lowering cardiac output and causing hypotension. This is an important early indicator of PEEP-induced hemodynamic compromise that requires prompt assessment and adjustment of ventilator settings.
Rationale for Incorrect Answers
2. Decreased PaO₂: PEEP is designed to improve oxygenation; a decrease in PaO₂ usually indicates a problem with lung compliance, secretions, or oxygen delivery, not direct hemodynamic compromise from PEEP.
3. Increased crackles: Crackles suggest pulmonary edema or fluid overload, which is not an immediate or reliable indicator of high PEEP effects.
4. Decreased spontaneous respirations: In ACV, the ventilator delivers full breaths; spontaneous respirations are minimal or absent and do not indicate PEEP-related hemodynamic compromise.
Take-Home Points
- High PEEP increases intrathoracic pressure, which can decrease venous return and cardiac output, causing hypotension.
- Monitor blood pressure and assess for signs of hemodynamic instability during PEEP therapy.
- Adjust PEEP carefully to balance oxygenation benefits with cardiovascular effects.
Correct Answer is C
Explanation
A mechanically ventilated, orally intubated patient who is restless and anxious is at risk for accidental extubation, even if oxygen saturation is adequate. The first priority is to reduce agitation safely through sedation and continuous presence of a caregiver or nurse, addressing both comfort and safety before considering restraints.
Rationale for Correct Answer
3. Administer sedatives and have a caregiver stay with the patient: Sedation decreases anxiety and restlessness, reducing the likelihood of self-extubation or tube displacement. A caregiver or nurse provides constant supervision, ensuring rapid intervention if the patient attempts to pull at the tube. This approach addresses the root cause of agitation while maintaining patient safety.
Rationale for Incorrect Answers
1. Obtain an order and apply soft wrist restraints: Restraints should be a last resort after sedation and close monitoring fail. Applying restraints first does not address anxiety, may increase agitation, and carries ethical considerations.
2. Remind the patient that he needs the tube inserted to breathe: Verbal reassurance alone is insufficient for a patient who is physiologically and psychologically distressed and may not fully comprehend due to sedation or confusion.
4. Move the patient to an area close to the nurses’ station for closer observation: While closer observation may help, it does not reduce agitation or prevent self-extubation by itself; sedation and continuous presence are more effective first-line interventions.
Take-Home Points
- Sedation and constant supervision are first-line measures to prevent accidental extubation in anxious, intubated patients.
- Restraints are a secondary measure and should be used only if sedation and monitoring are insufficient.
- Always assess agitation, pain, and discomfort in ventilated patients to guide safe interventions.
- Preventing self-extubation reduces risk of hypoxia, airway trauma, and ventilator complications.
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