Medical Surgical Ventilator Settings & Mechanical Ventilation #1

Question

Two family members are at the bedside of the client and call the nurse after loud alarms sound from the ventilator. The nurse comes into the intensive care room and performs which action?

Answers

  1. Stand at the ventilator and push the alarm silence button and explain that the visitors can continue with their visit.
    • Rationale:

      This answer is not correct because the nurse should not put client safety at risk through silencing ventilator alarms. Ventilator alarms are intended to alert the nurse to complications with oxygenation/ventilation and should never be silenced.

  2. Change the ventilator settings to client assist and lower the tidal volumes.
    • Rationale:

      This answer is not correct because the nurse should never change ventilator settings without informing the respiratory team and healthcare provider. This action is beyond the nursing scope of practice.

  3. Call the health care provider immediately and ask the family to leave the room.
    • Rationale:

      This answer is not correct because it is not necessary to clear the room and call the health care provider, since assessment of the reason behind the high-pressure alarms should be performed first.

  4. Assess the client, all ventilator tubing, connections, and call respiratory therapy if needed.
    • Rationale:

      This answer is correct because the nurse should interpret the alarm as a high pressure alarm usually caused by obstruction from secretions, coughing, tubing compression, endotracheal tube migration, or the client biting on the endotracheal tube.

Overview

The focus of this question is determining the most appropriate action to perform when troubleshooting mechanical ventilator alarms. First and foremost, assessment of the client should always be the nurse’s priority in any situation.

Explanation

Learning Outcomes

Clients who are intubated and mechanically ventilated require frequent monitoring in order to ensure that the ventilator is functioning properly and that the client is not experiencing potential complications. One aspect of the ventilator assessment includes troubleshooting when the ventilator alarms. A ventilator alarm should never be ignored but rather the nurse should immediately address any alarm by performing a rapid, focused assessment of the client as well as assessing the ventilator and alerting respiratory therapy as indicated.

Test Taking Tip

Assessment is the first step in the nursing process! Assessing the client is always first before machines.

Video Rationale