The high-pressure alarm on a patient's mechanical ventilator is alarming. What actions should the nurse take? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Assess if the patient needs to be suctioned.
2. Assess if the patient is biting the tube.
3. Assess if the patient has rolled onto the tube.
4. Assess for a mucous plug.
5. Assess for respiration synchrony with the ventilator.
1,2,3,4
Rationale 1: High-pressure alarms should signal the nurse to check the patient to determine if suctioning is needed.
Rationale 2: High-pressure alarms should signal the nurse to check if the patient is biting the endotracheal tube.
Rationale 3: High-pressure alarms should signal the nurse to check if the patient has rolled onto the endotracheal tube.
Rationale 4: High-pressure alarms should signal the nurse to assess if the patient is experiencing a mucous plug.
Rationale 5: A high-pressure alarm does not indicate asynchronous respirations.
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