A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?

Malfunction of the alarm button.

A cut or slice in the tubing from the ventilator.

Higher than normal endotracheal cuff pressure.

A kink in the ventilator tubing.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Malfunction of the alarm button is unlikely to be the cause of increased peak airway pressure. The alarm is designed to alert the nurse to a problem with the ventilator or the patient’s airway, not to malfunction itself. Therefore, this is not the first thing the nurse should assess.

Choice B Reason:

A cut or slice in the tubing from the ventilator could cause a loss of pressure or air leak, but it would not typically result in increased peak airway pressure. Instead, it would likely cause a decrease in pressure and potentially trigger a different alarm.

Choice C Reason:

Higher than normal endotracheal cuff pressure can contribute to increased peak airway pressure. However, it is not the most immediate concern compared to a kink in the tubing, which can completely obstruct airflow and rapidly compromise the patient’s ventilation.

Choice D Reason:

A kink in the ventilator tubing is a common and immediate cause of increased peak airway pressure. It obstructs the flow of air, leading to a buildup of pressure in the system. This is the first thing the nurse should assess and correct to ensure the patient is receiving adequate ventilation.

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Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/h is not appropriate for a client with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion). This solution is hypotonic and can exacerbate the condition by increasing water retention and worsening hyponatremia. Therefore, this choice is not included in the plan of care.

Choice B Reason:

Obtaining daily weight is crucial for monitoring fluid balance in clients with SIADH. Daily weights help detect fluid retention or loss, which is essential for managing the condition. Accurate weight measurements can indicate changes in fluid status and guide adjustments in treatment.

Choice C Reason:

Maintaining seizure precautions is vital for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if seizures occur.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in clients with SIADH. Hypertonic saline helps increase serum sodium levels, which is critical for correcting the electrolyte imbalance. This intervention should be closely monitored to avoid rapid changes in sodium levels.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. The condition is characterized by excessive water retention, and increasing fluid intake can worsen hyponatremia. Instead, fluid restriction is typically recommended to manage the condition effectively.

Correct Answer is ["31"]

Explanation

Let’s calculate the IV infusion rate step by step.

Step 1: Determine the total volume to be infused.

The total volume ordered is 1,000 mL.

Step 2: Determine the total time for the infusion.

The total time is 8 hours.

Step 3: Calculate the infusion rate in mL per hour.

Total volume (1,000 mL) ÷ Total time (8 hours) = 125 mL per hour.

Result: 125

Step 4: Determine the drop factor.

The IV tubing delivers 15 drops per milliliter.

Step 5: Calculate the infusion rate in drops per minute.

Infusion rate (125 mL per hour) × Drop factor (15 drops per mL) = 1,875 drops per hour.

Result: 1,875

Step 6: Convert the infusion rate to drops per minute.

Total drops per hour (1,875 drops) ÷ 60 minutes = 31.25 drops per minute.

Result: 31.25

Step 7: Round the result to the nearest whole number if necessary.

31.25 rounded to the nearest whole number is 31.

The nurse should run the IV infusion at a rate of 31 drops per minute.

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A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?

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Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The doctor orders dextrose 5% in water 1,000 mL to be infused over 8 hours. The IV tubing delivers 15 drops per milliliter. The nurse in charge should run the IV infusion at a rate of: NOTE: Enter ONLY THE NUMBER DO NOT enter the unit of measurement

Correct Answer is ["31"]

Explanation

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A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?