The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding

Question

The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to: a. ask the respiratory therapist to get a new ventilator.
b. call the rapid response team to assess the patient.
c. continue to find the cause of the alarm and fix it.
d. manually ventilate the patient while calling for a respiratory therapist.

Answer 1

D
The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.