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 C
Explanation
A. Data comparison should be done after establishing the standards and collecting data.
B. While data collection is important, the first step is to determine what the accepted hand hygiene standards are.
C. This is the correct answer. The first step in an audit process is to determine the accepted hand hygiene standards to provide a basis for evaluation.
D. Corrective measures should only be taken after data has been collected and analyzed.
Correct Answer is C
Explanation
A. Lying down after meals increases reflux by allowing stomach contents to flow back into the esophagus.
B. High-fat foods delay gastric emptying, worsening heartburn.
C. Carbonated beverages may help neutralize stomach acid and provide symptom relief when sipped in moderation.
D. Hot herbal tea can relax the lower esophageal sphincter, exacerbating reflux.
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