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 C

Explanation

A. The non-dominant arm should be used when possible to minimize interference with daily activities.

B. The palmar side of the wrist is highly sensitive and should be avoided due to the risk of discomfort and nerve injury.

C. This is the correct answer. The nurse should select a site proximal to previous venipuncture sites to maintain vein integrity and avoid complications such as infiltration or phlebitis.

D. Using a larger gauge catheter increases the risk of phlebitis rather than preventing it.

A. Check the client's vital signs every 15 min. B. Give the naloxone slowly for 15 seconds. C. Expect the onset of naloxone to occur in 15 min. D. Anticipate the effects of naloxone to last for 24 hr.

Correct Answer is A

Explanation

A. Vital signs should be monitored every 15 minutes because naloxone has a short duration and the client may experience opioid re-sedation as the antagonist wears off.

B. Naloxone should be administered over 2 minutes, not 15 seconds, to reduce abrupt opioid withdrawal symptoms.

C. Naloxone has a rapid onset (1-2 minutes IV, 2-5 minutes IM).

D. The effects of naloxone last only 30-90 minutes, requiring repeated doses if opioids are still in the system.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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