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?

The patient is coughing

The ETT has a cuff leak

The ventilator tubing has become disconnected

The patient is complaining of a headache 8/10 pain

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B,A,C

Explanation

Choice A reason:

Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.

Choice B reason:

Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.

Choice C reason:

Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.

A. Maintaining proper body positioning B. Preventing infection C. Maintaining adequate organ perfusion D. Avoiding the use of vasopressors

Correct Answer is C

Explanation

Choice A reason:

Maintaining proper body positioning is important for the overall care of a patient, but it is not the priority in the context of organ donation. The primary focus should be on ensuring the viability of the organs for transplantation.

Choice B reason:

Preventing infection is critical in any clinical setting, particularly in the care of an organ donor, as infections can compromise the quality of the organs. However, it is not the immediate priority action. The most crucial aspect is maintaining organ perfusion to ensure the organs remain viable for transplantation.

Choice C reason:

Maintaining adequate organ perfusion is the priority nursing action in caring for an organ donor. Adequate perfusion ensures that the organs receive sufficient blood flow and oxygen, which is essential for preserving their function until they can be transplanted. This action takes precedence over other considerations to ensure the success of the organ donation process.

Choice D reason:

Avoiding the use of vasopressors is important because they can impact organ perfusion and function. However, if necessary, vasopressors may be used to maintain adequate blood pressure and perfusion. The overall priority remains ensuring adequate perfusion to preserve organ function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B,A,C

Explanation

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Correct Answer is C

Explanation

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