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 D

Explanation

A. Fried chicken – High-fat foods like fried chicken relax the lower esophageal sphincter (LES), worsening GERD symptoms.

B. Tomato soup – Acidic foods like tomatoes can irritate the esophagus and should be avoided.

C. Hot cocoa – Chocolate and caffeine-containing drinks relax the LES and increase acid production, worsening GERD.

D. Bran cereal – This is a good choice because high-fiber foods promote digestion and help reduce acid reflux.

A. Rearrange furniture to clear walkways. B. Use container lids of different shapes to indicate times of administration, C. Cover appliance cords with throw rugs. D. Visit the client once per month to assess medication usage.

Correct Answer is B

Explanation

A. Rearrange furniture to clear walkways – While important for fall prevention, it does not directly address medication safety.

B. Use container lids of different shapes to indicate times of administration – Correct. Using distinct tactile markers helps clients with vision loss distinguish medications and adhere to their regimen.

C. Cover appliance cords with throw rugs – Incorrect. Throw rugs are a tripping hazard and should be removed, not used to cover cords.

D. Visit the client once per month to assess medication usage – Monthly visits may not be sufficient for ensuring medication adherence and safety.

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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

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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?