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 C

Explanation

Choice A reason:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B reason:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C reason:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D reason:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

A. Heparin B. Vitamin K C. Iron D. Protamine

Correct Answer is B

Explanation

Choice A reason:

Administering Heparin to a patient who is already taking Warfarin and experiencing rectal bleeding is not appropriate. Heparin is an anticoagulant, similar to Warfarin, and would not help in reversing the anticoagulant effects of Warfarin. Instead, it could potentially exacerbate the bleeding.

Choice B reason:

Vitamin K is the correct answer because it acts as an antidote to Warfarin. Warfarin works by inhibiting the synthesis of Vitamin K-dependent clotting factors, so administering Vitamin K helps to reverse the effects of Warfarin and promote blood clotting, which is necessary to control the rectal bleeding in this patient.

Choice C reason:

Iron is not the appropriate treatment for rectal bleeding due to Warfarin. While iron supplements can help with anemia (which might result from chronic blood loss), they do not address the immediate need to reverse the anticoagulant effects of Warfarin and stop the active bleeding.

Choice D reason:

Protamine is used to reverse the effects of Heparin, not Warfarin. Therefore, administering Protamine would not be effective in addressing the Warfarin-induced rectal bleeding in this patient.

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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

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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