A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?
Troubleshoot the ventilator until the problem is found.
Take the patient off the ventilator and manually ventilate.
Call the respiratory therapist for help.
Silence the ventilator alarms until the problem is resolved.
The Correct Answer is B
Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.
Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.
Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.
Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: A potassium level of 7.0 mEq/L risks lethal arrhythmias, necessitating cardiac monitoring. This aligns with hyperkalemia management, making it a correct priority action the nurse would plan to ensure the client’s safety and detect cardiac changes promptly.
Choice B reason: Notifying the provider is critical for a potassium level of 7.0 mEq/L, as urgent interventions like insulin or dialysis may be needed. This aligns with acute care protocols, making it a correct priority action for the nurse to address hyperkalemia.
Choice C reason: NPO status with ice chips is unrelated to hyperkalemia management, which focuses on lowering potassium. Cardiac monitoring is a priority, making this incorrect, as it’s not relevant to the nurse’s urgent actions for a client with severe hyperkalemia.
Choice D reason: Reviewing medications identifies potassium-containing or retaining drugs, preventing further elevation of 7.0 mEq/L. This aligns with hyperkalemia treatment, making it a correct priority action the nurse would plan to manage the client’s electrolyte imbalance effectively.
Choice E reason: Extra IV fluids (500 mL) may dilute potassium but risk fluid overload in acute kidney injury. Notifying the provider is more urgent, making this incorrect, as it’s not a priority compared to the nurse’s focus on immediate hyperkalemia interventions.
Correct Answer is A
Explanation
Choice A reason: Limiting dietary fiber is incorrect for IBS, as soluble fiber helps regulate bowel movements. This indicates a need for further teaching, making it the correct statement, as it contradicts the nurse’s instructions to include fiber for IBS symptom management.
Choice B reason: Drinking 8 to 10 cups of fluid daily supports hydration and bowel function in IBS, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the fiber limitation statement requiring further client education.
Choice C reason: Eating regular meals and chewing well stabilizes digestion in IBS, reflecting correct understanding. This is incorrect, as it aligns with the nurse’s instructions, unlike the fiber limitation statement that indicates a need for further teaching.
Choice D reason: Taking prescribed medications to regulate bowel patterns is appropriate for IBS management, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the incorrect fiber limitation statement needing further client instruction.
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