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. Changing the inner cannula on a tracheostomy: This procedure falls within the RN's scope of practice, as it involves basic tracheostomy care and maintenance, which nurses commonly perform.
B. Administering a platelet transfusion: Administering blood and blood products, including platelet transfusions, is within the RN's scope of practice, provided the nurse has appropriate training and competency.
C. Irrigation of an external ear canal: Irrigation of an external ear canal is a routine nursing procedure that falls within the RN's scope of practice, as long as it does not involve invasive procedures beyond irrigation.
D. Inserting a tunneled central venous catheter: Inserting tunneled central venous catheters is typically performed by advanced practice nurses or physicians with specific training and certification, such as nurse practitioners or interventional radiologists. This procedure is beyond the scope of practice for RNs and requires specialized skills and knowledge.

A. Disulfiram B. Acamprosate C. Diazepam D. Naltrexone

Correct Answer is C

Explanation

A. Disulfiram: Disulfiram is used in the treatment of alcohol dependence by creating unpleasant effects (such as nausea and vomiting) when alcohol is consumed. It is not indicated for the management of seizures associated with alcohol withdrawal.
B. Acamprosate: Acamprosate is used in the treatment of alcohol dependence to help maintain abstinence by reducing cravings for alcohol. It is not indicated for the management of seizures associated with alcohol withdrawal.
C. Diazepam: Diazepam is a benzodiazepine medication commonly used to treat seizures associated with alcohol withdrawal due to its anticonvulsant properties. It helps to prevent and control seizures by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain.
D. Naltrexone: Naltrexone is used in the treatment of alcohol dependence by reducing the pleasurable effects of alcohol and decreasing the desire to drink. It is not indicated for the management of seizures associated with alcohol withdrawal.

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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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