While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Suction the client's airway.

Look for a leak in the tube's cuff

Tighten the tubing connections.

Request insertion of a tracheostomy tube

Answer and Explanation

The Correct Answer is A

A. Suction the client's airway – This is the correct answer. A high-pressure alarm on a ventilator usually indicates an obstruction, such as mucus plugging or secretions in the airway. Suctioning helps clear the obstruction.

B. Look for a leak in the tube's cuff – A leak would trigger a low-pressure alarm, not a high-pressure alarm.

C. Tighten the tubing connections – Loose connections generally cause low-pressure alarms rather than high-pressure alarms.

D. Request insertion of a tracheostomy tube – This may be necessary for long-term ventilation, but it is not the immediate intervention for a high-pressure alarm.

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Correct Answer is B

Explanation

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

A. Shake both insulin vials for 2 min before withdrawing the doses. B. Administer the mixture within 5 min of preparing it. C. Withdraw the NPH insulin before the regular insulin. D. Inject air into the regular insulin vial before injecting air into the NPH vial.

Correct Answer is B

Explanation

A. Insulin vials should not be shaken because this can create air bubbles, leading to inaccurate dosing. Instead, NPH insulin should be gently rolled between the palms to evenly mix the suspension. Regular insulin does not require mixing.

B. Once regular and NPH insulin are mixed, they should be administered promptly to maintain their stability and effectiveness. Delaying administration may alter insulin absorption, leading to unpredictable glucose control.

C. Regular insulin should be drawn up before NPH insulin to prevent contaminating the clear regular insulin with the cloudy NPH insulin. The correct order is to inject air into the NPH vial first (without withdrawing insulin), then inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.

D. The correct technique is to first inject air into the NPH vial, then inject air into the regular insulin vial. This prevents contamination and maintains sterility. However, when withdrawing insulin, regular insulin is drawn first to prevent mixing of NPH insulin into the regular insulin vial.

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While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

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