The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?
Notify the health care provider
Insert an oral airway to prevent the client from biting the tube
Suction the client and reset the alarm
Disconnect the client from the ventilator and use a manual resuscitation bag
The Correct Answer is D
A. Notify the healthcare provider: While notifying the healthcare provider may eventually be necessary, the first priority is to ensure the client's airway is protected and they are receiving adequate ventilation. The provider can be notified after immediate interventions have been made to stabilize the patient.
B. Insert an oral airway to prevent the client from biting the tube: Inserting an oral airway may be necessary if the client is biting the endotracheal tube, but this is unlikely the first action needed in response to a low-pressure alarm. If the client is not biting the tube, this action will not address the potential causes of the low-pressure alarm, such as a disconnection, leak, or circuit issue.
C. Suction the client and reset the alarm: While suctioning is an important intervention if secretions are the cause of ventilation issues, it is not the first action when the source of the low-pressure alarm is unclear. If a disconnection or leak is the issue, suctioning will not resolve the problem, and the nurse risks delaying appropriate action to address the source of the alarm. The priority is ensuring the client’s ventilation is not compromised, which is best accomplished by using a manual resuscitation bag until the problem is identified and corrected.
D. Disconnect the client from the ventilator and use a manual resuscitation bag: If the source of the low-pressure alarm cannot be identified after checking the client and the ventilator, the first priority is to ensure that the client continues to receive adequate ventilation. Disconnecting the client from the ventilator and using a manual resuscitation bag (Ambu bag) allows for immediate support of the patient's ventilation while the nurse investigates the cause of the alarm. This ensures the client's oxygenation and ventilation needs are met until the problem is resolved. It is critical to address any potential loss of positive pressure or leaks in the ventilator system promptly to avoid respiratory distress or failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.9"]
Explanation
Step-by-Step Solution:
Convert the toddler's weight from pounds to kilograms.
1 pound is =0.453592 kilograms.
So, 26 pounds = 26 x 0.453592 = 11.793592 kilograms.
Calculate the total daily dose of prednisolone.
The prescribed dose is 2 mg/kg/day.
The toddler weighs 11.793592 kg.
The total daily dose = 2 mg/kg/day x 11.793592 kg = 23.587184 mg/day.
Determine the dose per administration.
The total daily dose is divided into two equal doses (every 12 hours).
The dose per administration = 23.587184 mg/day / 2 = 11.793592 mg per dose.
Calculate the volume of prednisolone syrup to administer.
The available prednisolone syrup is 15 mg/5 ml.
We need to administer 11.793592 mg per dose.
To find the volume, we can set up a proportion:
15 mg / 5 ml = 11.793592 mg / x ml
Cross-multiplying:
15x = 5 x 11.793592
Solving for x:
x = (5 x 11.793592) / 15 = 3.931197 ml
Round the answer to the nearest tenth.
3.9 ml.
Correct Answer is D
Explanation
A. Notify the healthcare provider: While notifying the healthcare provider may eventually be necessary, the first priority is to ensure the client's airway is protected and they are receiving adequate ventilation. The provider can be notified after immediate interventions have been made to stabilize the patient.
B. Insert an oral airway to prevent the client from biting the tube: Inserting an oral airway may be necessary if the client is biting the endotracheal tube, but this is unlikely the first action needed in response to a low-pressure alarm. If the client is not biting the tube, this action will not address the potential causes of the low-pressure alarm, such as a disconnection, leak, or circuit issue.
C. Suction the client and reset the alarm: While suctioning is an important intervention if secretions are the cause of ventilation issues, it is not the first action when the source of the low-pressure alarm is unclear. If a disconnection or leak is the issue, suctioning will not resolve the problem, and the nurse risks delaying appropriate action to address the source of the alarm. The priority is ensuring the client’s ventilation is not compromised, which is best accomplished by using a manual resuscitation bag until the problem is identified and corrected.
D. Disconnect the client from the ventilator and use a manual resuscitation bag: If the source of the low-pressure alarm cannot be identified after checking the client and the ventilator, the first priority is to ensure that the client continues to receive adequate ventilation. Disconnecting the client from the ventilator and using a manual resuscitation bag (Ambu bag) allows for immediate support of the patient's ventilation while the nurse investigates the cause of the alarm. This ensures the client's oxygenation and ventilation needs are met until the problem is resolved. It is critical to address any potential loss of positive pressure or leaks in the ventilator system promptly to avoid respiratory distress or failure.
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