Respiratory Question #42

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 the visitors can continue with their visit.
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  2. Change the ventilator settings to client assist and lower the tidal volumes.
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  3. Call the health care provider immediately and ask the family to leave the room.
    • Rationale:
  4. Assess all ventilator tubing, connections, and client, and call respiratory department if needed.
    • Rationale:

Overview

Explanation

The nurse should interpret the alarm as a high pressure alarm usually caused by obstruction from secretions, coughing, tubing compression, endotracheal tube migration, or client biting on the endotracheal tube. The nurse should not put client safety at risk through silencing alarms, and the nurse should never change ventilator settings without informing the respiratory team and healthcare provider. It is not necessary to clear the room and call the health care provider since the assessment of the reason behind the high-pressure alarm should be performed first.

Learning Outcomes

Test Taking Tip

Video Rationale