A ventilated client has become hypoxic, with a pulse oximeter reading falling from 98% to 88%. The high-pressure alarm is sounding on the ventilator. The nurse has checked the tubing integrity and found no problems
The nurse has assessed the lung sounds and the sounds are equal bilaterally, but adventitious sounds are present. What action will the nurse take next? 1. Suction the client.
2. Contact the health care provider.
3. Turn the client on his side.
4. Silence the alarm.
Suction the client.
Rationale: When the tubing integrity is intact and the high-pressure alarm is sounding, along with pulse oximeter readings falling from 98% to 88% and adventitious breath sounds present, this indicates the client needs to be suctioned. The health care provider will not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia. Turning the client on his side has no purpose. Silencing the alarm will not resolve the issue.
You might also like to view...
The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem?
a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs
Order: Vancomycin 40 mg/kg/d divided into q.6h. doses IV. The manufacturer recommends reconstituting 500 mg vial with 10 mL, yielding 50 mg/mL. How many milliliters will you administer for each dose if the client weighs 90 lb?
1. 180 mL 2. 18 mL 3. 8.2 mL 4. 3.4 mL
A group of nursing students are reviewing information about adrenergic blockers in preparation for an examination. The students demonstrate understanding of the information when they identify which of the following as an a/b-adrenergic blocker?
Select all that apply. A) Phentolamine B) Bisoprolol C) Nadolol D) Carvedilol E) Labetalol
Nitrous oxide is being administered to a child with extensive burn injuries. Which is the purpose of this medication?
a. Promote healing. b. Prevent infection. c. Provide anesthesia. d. Improve urinary output.