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
Explanation
Choice A reason: Palpation of a thrill, a vibrating sensation, indicates blood flow and patency in an arteriovenous fistula. This aligns with hemodialysis access assessment, making it the correct finding the nurse would use to confirm the fistula is patent.
Choice B reason: A radial pulse in the wrist is normal but doesn’t confirm fistula patency, which requires a thrill. Palpation of a thrill is specific, making this incorrect, as it’s not a direct indicator of fistula function in hemodialysis preparation.
Choice C reason: Enlarged vessels may suggest fistula development but don’t confirm active flow. A thrill indicates patency, making this incorrect, as it’s less specific than the nurse’s assessment of a palpable thrill over the fistula site.
Choice D reason: Capillary refill less than 3 seconds assesses distal perfusion, not fistula patency. Palpation of a thrill is the standard, making this incorrect, as it’s unrelated to the nurse’s evaluation of the arteriovenous fistula for hemodialysis.
Correct Answer is B
Explanation
Choice A reason: White bread and carbonated beverages may trigger IBS symptoms like bloating. Chicken, rice, and broccoli are low-irritant, making this incorrect, as it includes potential IBS triggers compared to the nurse’s teaching on a suitable diet for symptom management.
Choice B reason: Broiled chicken, brown rice, and steamed broccoli are low-irritant, high-fiber foods, with apple juice being IBS-friendly. This aligns with dietary recommendations for IBS, making it the correct menu selection showing the client’s understanding of the nurse’s teaching.
Choice C reason: Grilled cheese’s dairy and hot tea’s caffeine may exacerbate IBS symptoms. Chicken and rice are safer, making this incorrect, as it includes potential irritants compared to the nurse’s teaching on a diet that minimizes IBS symptom triggers for the client.
Choice D reason: Coffee, even with low-fat milk, is a known IBS trigger due to caffeine. Chicken, rice, and broccoli are better choices, making this incorrect, as it includes a stimulant that contradicts the nurse’s dietary teaching for managing irritable bowel syndrome effectively.
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