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. Wire cutters:
Wire cutters are typically not necessary for postoperative care following a thoracotomy with chest tube placement. They are more commonly used in situations such as removing orthopedic hardware or cutting wires in emergency situations. Therefore, wire cutters are not essential equipment for this particular procedure.

B. Montgomery straps:
Montgomery straps are adhesive strips used to secure dressings or bandages without the need for tape. While they can be useful in some postoperative situations, they are not specifically required for a thoracotomy with chest tube placement.

C. Tracheostomy tray:

A tracheostomy tray contains equipment necessary for performing tracheostomy care, such as sterile gloves, tracheostomy tubes, and suctioning equipment. It is not directly related to thoracotomy or chest tube care post op.

D. Padded clamp:
A padded clamp, or chest tube holder, is a device used to secure chest tubes in place and prevent them from being accidentally dislodged. It is an essential piece of equipment for postoperative care following a thoracotomy with chest tube placement, as it helps maintain the integrity of the chest tubes and prevents complications such as air leaks or pneumothorax.

A. "Incident report completed. A copy will be placed in the client's medical record. B. "Prescribed dressing change was accidentally omitted during the previous shift." C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.

Correct Answer is B

Explanation

A. "Incident report completed. A copy will be placed in the client's medical record." This statement indicates the completion of the incident report but lacks essential information about what incident occurred. It does not provide details necessary for understanding the nature of the incident.
B. "Prescribed dressing change was accidentally omitted during the previous shift." This statement clearly identifies the nature of the incident, stating that a prescribed dressing change was missed. It provides factual information without assigning blame, which is appropriate for an incident report.
C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." While this statement acknowledges the omission, it lacks details about the incident and focuses on future actions rather than accurately documenting what occurred.
D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." This statement does not accurately represent the situation. It implies that the dressing change was not completed due to the dressing not appearing soiled, which may not be the case. It does not acknowledge the omission of the prescribed dressing change.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

Correct Answer is D

Explanation

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is B

Explanation

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