Difficulty: Medium
Average Score: 87%
Simulated
A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?
Correct answer
D
Rationale
The correct answer is D: Deliver breaths manually with a resuscitation bag. This action is necessary to ensure the client is receiving adequate oxygenation and ventilation while troubleshooting the high-pressure alarm. By manually delivering breaths with a resuscitation bag, the nurse can support the client's respiratory effort and prevent hypoxia. This immediate intervention takes priority in managing the client's respiratory distress.
A: Re-evaluating the client for an ET cuff leak is important but not as urgent as providing manual breaths.
B: Assessing for disconnected tubing is important but not as urgent as providing manual breaths.
C: Decreasing the ventilator flow rate may not address the underlying cause of the high-pressure alarm and could potentially worsen the respiratory distress.
In summary, manually delivering breaths with a resuscitation bag is the most appropriate action to address the client's immediate respiratory distress while further assessment and troubleshooting can be performed.
A: Re-evaluating the client for an ET cuff leak is important but not as urgent as providing manual breaths.
B: Assessing for disconnected tubing is important but not as urgent as providing manual breaths.
C: Decreasing the ventilator flow rate may not address the underlying cause of the high-pressure alarm and could potentially worsen the respiratory distress.
In summary, manually delivering breaths with a resuscitation bag is the most appropriate action to address the client's immediate respiratory distress while further assessment and troubleshooting can be performed.