The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.)
a. Assess the tubing for kinks.
b. Assess whether the tubing has become disconnected.
c. Determine the need for suctioning.
d. Call the health care provider.
e. Call the Rapid Response Team.
f. Auscultate the client's lungs.
A, C, F
Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the air-way. The nurse first should assess the client and determine whether he or she needs to be suc-tioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.
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