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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Remove the linen from the client's room after each bed change – Linens should not be removed unnecessarily, as this could spread radiation contamination.
B. Instruct the client's family members to stay 1 m (3 ft) away from the client – This is correct because maintaining distance reduces radiation exposure risk for visitors.
C. Keep the client in bed during treatment – This is not always required. The client may have limited activity, but strict bed rest is not necessary unless prescribed.
D. Limit each of the client's visitors to 2 hours per day – Time should be limited, but the recommended duration is typically 30 minutes per day, not 2 hours.
Correct Answer is D
Explanation
A. Tachycardia – Digoxin toxicity typically causes bradycardia, not tachycardia, due to its effect on the AV node.
B. Hearing loss – Digoxin does not commonly cause hearing loss; ototoxicity is more associated with aminoglycoside antibiotics.
C. Insomnia – While some neurological symptoms may occur, insomnia is not a classic sign of digoxin toxicity.
D. Blurred vision – This is the correct answer. Digoxin toxicity can cause visual disturbances such as blurred vision, yellow-green halos, and scotomas. Other signs include nausea, vomiting, anorexia, fatigue, and cardiac arrhythmias.
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