The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system
What is the nurse's best action? a. Change the client's position.
b. Suction the client.
c. Assess lung sounds.
d. Turn off the pressure alarm.
C
One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath.
You might also like to view...
A bystander was killed during a robbery 2 weeks ago. His widow, who has schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response
a. "Are you hearing voices at night?" b. "I am worried about how much you are crying. Your grief over your husband's death has gone on too long.". c. "This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program.". d. "The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings.".
The informatics nurse learns that a close friend is admitted to the organization. What should the nurse do demonstrate ethical behavior?
A) Refrain from accessing the medical record. B) Access at the friend's medical record at the bedside. C) Look at the friend's medical record in a secure area. D) Ask a nurse on the care area about the friend's health problem.
Which nursing intervention is directed to the school-age child's independent management of asthma symptoms?
1. Assess the child and family's level of understanding of asthma. 2. Encourage the child to use the flow meter and record results every day. 3. Discuss with the child how to tell friends about asthma. 4. Teach the parents proper use of inhalers.
Diuretics are used in the treatment of all the following, except:
a. edema. c. obesity. b. ascites. d. hypertension.