The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Apply tight-fitting clothing

Complete frequent skin checks

Initiate a bowel regimen program

Insert an indwelling Foley catheter

Restrict all patient visitors

Answer and Explanation

Correct Answer : B,C,D

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

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Correct Answer is A

Explanation

Choice A reason:

The patient coughing is the most likely cause of the high pressure alarm on a mechanical ventilator. Coughing can increase airway resistance and pressure, triggering the alarm. This is a common occurrence and should be addressed by assessing the patient's need for suctioning or other interventions to relieve the cough.

Choice B reason:

An endotracheal tube (ETT) cuff leak would typically cause a low pressure alarm, not a high pressure alarm. A cuff leak results in a loss of pressure within the ventilator circuit, leading to insufficient ventilation and a different alarm response.

Choice C reason:

If the ventilator tubing becomes disconnected, it would result in a low pressure alarm due to the loss of circuit integrity. A disconnection is a serious issue that needs immediate correction but does not cause high pressure alarms.

Choice D reason:

The patient's complaint of a headache does not directly relate to a high pressure alarm on the ventilator. While patient discomfort should always be addressed, it is not the most likely cause of the alarm in this scenario.

A. Need for increased FiO2 administration. B. Increased inflation of the lungs. C. Prevention of alveolar collapse during expiration. D. Prevention of barotrauma to the lung tissue.

Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

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The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

Correct Answer is A

Explanation

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

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