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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Schedule activities late in the day and in the evening:

Scheduling activities late in the day is not an ideal approach for managing fatigue in clients with MS. Fatigue typically worsens as the day progresses, and clients with MS often experience more energy depletion in the late afternoon and evening. Therefore, the best time to schedule demanding activities is earlier in the day when the client may have more energy. Scheduling strenuous tasks late in the day may exacerbate fatigue and lead to physical and emotional exhaustion.

B. Provide supplemental oxygen when fatigued:

While oxygen therapy is appropriate for clients with respiratory issues or other conditions that affect oxygenation, it is not the most relevant intervention for addressing fatigue in MS. Fatigue in MS is primarily caused by neurological factors, muscle weakness, or impaired mobility, not by a lack of oxygen. The priority for MS-related fatigue is managing energy levels through activity planning and rest, not providing supplemental oxygen unless there is a specific indication of respiratory distress or hypoxia.

C. Teach the importance of hot showers to help relax:

Hot showers may help some individuals relax, but they are not the best intervention for managing fatigue in MS. In fact, heat can sometimes worsen symptoms in clients with MS, a phenomenon known as Uhthoff’s phenomenon, where heat increases neurological symptoms such as muscle weakness, fatigue, or visual disturbances. It is important to educate clients to avoid overheating, which could exacerbate fatigue or other symptoms. Instead, clients should focus on rest, energy conservation, and temperature regulation.

D. Have the client prioritize activities for the day: Fatigue is a common and debilitating symptom in clients with multiple sclerosis (MS), and it can significantly affect their daily functioning. One of the most effective interventions for managing fatigue in MS is to encourage the client to prioritize activities and manage their energy levels throughout the day. By scheduling the most important or demanding tasks earlier in the day when energy levels tend to be higher, clients can conserve energy for essential activities. Additionally, teaching clients to break tasks into smaller, manageable steps and incorporating frequent rest periods can help minimize fatigue and prevent overexertion. Prioritizing activities ensures that the client is not overwhelmed and can still maintain independence while managing their symptoms effectively.

A. Administer antiplatelet and anticoagulant medications to prevent further clot formation. B. Relieve the blockage in the coronary artery and restore blood flow to the heart muscle. C. Provide pain relief and initiate cardiac rehabilitation. D. Stabilize the dient's blood pressure and administer thrombolytic therapy.

Correct Answer is B

Explanation

A) Administer antiplatelet and anticoagulant medications to prevent further clot formation:
While antiplatelet and anticoagulant medications are essential in the management of STEMI to reduce the risk of further clot formation, they are not the primary goal of treatment in the immediate phase. These medications are typically administered before or during the procedure (such as during cardiac catheterization) to prevent new clots, but the primary objective is to restore blood flow to the heart muscle through reperfusion therapy, either by angioplasty or thrombolytics.

B) Relieve the blockage in the coronary artery and restore blood flow to the heart muscle:
This is the primary goal of treatment in STEMI. The most urgent intervention for a client with an ST elevation myocardial infarction (STEMI) is to relieve the blockage in the coronary artery and restore blood flow to the ischemic heart muscle. This is typically achieved through percutaneous coronary intervention (PCI) via cardiac catheterization, which involves either angioplasty (ballooning the artery) or stent placement. Restoring blood flow as quickly as possible reduces the extent of myocardial damage, improves the prognosis, and prevents complications like heart failure.

C) Provide pain relief and initiate cardiac rehabilitation:
Pain relief is important in the initial management of STEMI, typically with nitroglycerin and opioids for chest pain. However, the immediate goal in the ED is to address the underlying cause of the chest pain, which is the blockage of blood flow. Cardiac rehabilitation, while essential for long-term recovery, is not the immediate goal of treatment during the acute phase of a STEMI. The primary focus should be on restoring circulation to the affected myocardium.

D) Stabilize the client's blood pressure and administer thrombolytic therapy:
Stabilizing the client’s blood pressure is important, especially if the client is hypotensive, but it is not the main treatment goal. Thrombolytic therapy (clot-busting medications) is an option if PCI is not available or if it needs to be done within a certain time frame; however, the current best practice in STEMI is to perform PCI as soon as possible. Thrombolytics are typically used when PCI is not immediately available, but the ideal treatment is to restore blood flow through catheterization in a timely manner, as it is more effective than thrombolytic therapy at re-opening the blocked artery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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