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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hearing loss: While digoxin toxicity can affect various organ systems, including the auditory system, resulting in symptoms such as tinnitus (ringing in the ears), hearing loss is not a typical manifestation of digoxin toxicity.
B. Insomnia: Insomnia is not a common symptom of digoxin toxicity. Clients with digoxin toxicity are more likely to experience neurological symptoms such as confusion, visual disturbances, or changes in mental status.
C. Tachycardia: Digoxin toxicity can cause arrhythmias, but it typically presents with bradycardia rather than tachycardia. Bradycardia is a hallmark sign of digoxin toxicity due to its negative chronotropic effect on the heart.
D. Blurred vision: Blurred or yellow-tinted vision is a classic symptom of digoxin toxicity, often described as "yellow halos" around lights. Visual disturbances occur due to the drug's effects on the optic nerve and can progress to more severe manifestations, such as changes in color vision or photophobia. Therefore, blurred vision is a key indicator of digoxin toxicity and requires prompt assessment and intervention.
Correct Answer is B
Explanation
A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.
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