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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A pulse of 86 beats per minute is within the normal range for adults (60-100 beats per minute) and does not typically indicate a postoperative complication. While it is important to monitor vital signs, this pulse rate alone is not concerning unless accompanied by other abnormal findings.
Choice B Reason:
Hypoactive bowel sounds in all four quadrants can occur after surgery due to the effects of anesthesia and the surgical procedure itself. While it is important to monitor bowel sounds, hypoactivity is not immediately concerning unless it persists or is accompanied by other symptoms such as abdominal pain or distention. Therefore, this finding alone does not indicate an evolving complication.
Choice C Reason:
A blood pressure of 110/70 mm Hg is within the normal range for adults and does not typically indicate a postoperative complication. Blood pressure should be monitored regularly, but this reading alone is not concerning unless there are significant changes or other abnormal findings.
Choice D Reason:
Increasing restlessness is a concerning sign in the immediate postoperative period. It can indicate several potential complications, including pain, hypoxia, or the onset of delirium. Restlessness may also be an early sign of shock or other serious conditions that require prompt intervention. Therefore, this symptom warrants further assessment and immediate attention to determine the underlying cause and provide appropriate treatment.
Correct Answer is B
Explanation
Choice A Reason:
Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. The normal pH range for gastric contents is typically between 1.5 and 3.5. A pH of 7.35 is much higher than this range, indicating that the tube may not be in the stomach. Therefore, documenting the tube as correctly placed could lead to potential complications, such as improper feeding or medication administration.
Choice B Reason:
Notifying the health care provider is the correct action. A pH of 7.35 suggests that the nasogastric tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Immediate notification of the health care provider is crucial to prevent any adverse outcomes and to take corrective measures, such as confirming placement with an X-ray or re-inserting the tube.
Choice C Reason:
Checking for placement by auscultating for air injected into the tube is not a reliable method for verifying nasogastric tube placement. While this method was traditionally used, it has been found to be inaccurate and is no longer recommended. The sound of air entering the stomach can be misleading and does not confirm correct placement.
Choice D Reason:
Retesting the pH using another strip is not the best immediate action. While it is important to ensure the accuracy of the pH reading, a pH of 7.35 is significantly outside the normal gastric range, and retesting is unlikely to yield a different result. The priority should be to notify the health care provider to address the potential misplacement of the tube.
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