The nurse enters the patient's room as the ventilator alarms. When the nurse quickly assesses the patient, it is apparent that the patient is coughing against the ventilator. The most appropriate action for the nurse would be to
1. administer intravenous sedation.
2. silence the ventilator alarm and try to calm the patient.
3. manually bag the patient until the cause of the alarm is detected.
4. assess for presence of secretions and suction the patient.
4
Rationale: If the patient is coughing against the ventilator, the most likely cause is the presence of secretions that must be suctioned. Administering intravenous sedation may inadvertently stop the coughing, but it would result in negative consequences because the secretions would remain in the lungs. Silencing the alarm and trying to calm the patient does not represent the best judgment because the patient obviously is in need of suctioning. Manually bagging the patient should not be an issue because the nurse should readily be able to identify the problem.
You might also like to view...
An infant who weighs 7 kg and is 65 cm tall has a BSA of ______________
a. 0.36 m2 b. 0.15 m2 c. 9.29 m2 d. 3.05 m2
A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for which adverse effects associated with the use of xanthine derivatives?
a. Diarrhea b. Palpitations c. Bradycardia d. Drowsiness
Your client is female, 14 years old, well developed, and sexually active. She states that she is popular and has been dating a 16-year-old boy for the past year
She tells you that her period is late and that she is not using any contraceptives because her boyfriend doesn't approve of them. Which of the following nursing diagnoses would be most appropriate? 1. Ineffective health maintenance 2. Ineffective individual coping 3. Risk for infection 4. Delayed growth and development
After asking general assessment questions regarding spirituality, the nurse finds the client content and satisfied. How should the nurse conduct the rest of the assessment?
1. Specific questions regarding beliefs should be included. 2. The nurse should validate spiritual information with the client's family. 3. The assessment can now move on to physical assessment. 4. No further specific spiritual assessment is currently necessary.