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 A

Explanation

A. Herpes zoster – This vaccine is recommended for adults 50 years and older to prevent shingles, a painful rash caused by reactivation of the varicella-zoster virus. Older adults are at increased risk for complications from shingles, making this an essential immunization for this age group.

B. Diphtheria, tetanus, and acellular pertussis (DTaP) – This vaccine is primarily for children younger than 7 years old. Instead, older adults should receive the Tdap or Td vaccine as a booster every 10 years.

C. Human papillomavirus (HPV) – The HPV vaccine is recommended primarily for adolescents and young adults up to 26 years old to prevent cervical and other cancers. It is not typically given to older adults.

D. Rotavirus – The rotavirus vaccine is given to infants, as this virus causes severe diarrhea in young children. It is not needed in older adults.

A. Call the nurse who made the error to discuss the medication error. B. File an incident report within 24 hr. C. Notify the facility's pharmacist within 1 hr of the incident. D. Place an incident report in the client's medical record.

Correct Answer is B

Explanation

Rationale:

A. Call the nurse who made the error to discuss the medication error – This is not the appropriate action. The focus should be on client safety and proper reporting, not on discussing the error with the previous nurse.

B. File an incident report within 24 hr – This is the correct action. Incident reports should be completed promptly to document the error and ensure proper follow-up.

C. Notify the facility's pharmacist within 1 hr of the incident – While the pharmacist may be informed if a medication reversal or adjustment is needed, this is not the primary action to take.

D. Place an incident report in the client’s medical record – Incident reports are internal documents and should not be placed in the medical record to avoid legal concerns.

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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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