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?

Request insertion of a tracheostomy tube.

Suction the client's airway.

Tighten the tubing connections.

Look for a leak in the tube's cuff.

Answer and Explanation

The Correct Answer is B

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.

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Correct Answer is D

Explanation

A. Suggest that the client attend adult day care three times per week: While adult day care can provide socialization opportunities and supervision for older adults, it may not be suitable for all clients, especially those who are still independent and prefer to live in their own homes. Additionally, attending adult day care may not directly address the client's diabetes management needs.
B. Review assisted living accommodations with the client: Assisted living accommodations are typically considered for individuals who require assistance with activities of daily living (ADLs) or who can no longer live independently. Since the client in this scenario lives independently, reviewing assisted living accommodations may not be appropriate at this time.
C. Discuss a long-term care referral for the client with the provider: Long-term care referrals are generally reserved for individuals who require ongoing assistance with ADLs and medical care that cannot be adequately provided in a home setting. Since the client is currently living independently and managing their diabetes, a long-term care referral may not be necessary.
D. Instruct the client about the use of telehealth services: This is the most appropriate intervention for the client in a rural area who may have limited access to healthcare resources. Telehealth services can provide remote monitoring, education, and support for managing diabetes while allowing the client to remain in their home environment. This intervention promotes independence and supports the client's ability to manage their condition effectively while living in a rural area.

A. Atropine B. Flumazenil C. Naloxone D. Activated charcoal

Correct Answer is B

Explanation

A. Atropine: Atropine is not used to treat benzodiazepine toxicity. It is primarily indicated for treating bradycardia, organophosphate poisoning, and certain types of poisoning causing excessive muscarinic effects.
B. Flumazenil: Flumazenil is a benzodiazepine receptor antagonist and is used to reverse the sedative effects of benzodiazepine overdose or toxicity. It competitively inhibits the action of benzodiazepines at the receptor site, reversing their effects.
C. Naloxone: Naloxone is a medication used to reverse opioid overdose by competitively binding to opioid receptors and displacing opioid agonists. It is not effective in treating benzodiazepine toxicity.
D. Activated charcoal: Activated charcoal is used to absorb ingested toxins in cases of poisoning. However, it is not effective in treating benzodiazepine toxicity because benzodiazepines are not effectively absorbed by activated charcoal.

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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?

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