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    Rn ati comprehensive predictor 2023 proctored exam

    A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

    Explanation & Rationale

    A) "Decrease the ventilator flow rate.": Lowering the flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the client's respiratory distress. It is essential to identify and manage the cause first. B) "Deliver breaths manually with a resuscitation bag.": This is the most appropriate immediate action. Manually providing breaths ensures the client receives adequate ventilation while the nurse assesses the situation. This intervention prioritizes the client's safety and oxygenation during respiratory distress. C) "Assess for disconnected tubing.": While checking for disconnected tubing is an important step in troubleshooting the alarm, it may take time to assess and does not provide immediate support to the client in respiratory distress. Ensuring adequate ventilation is the priority. D) "Reevaluate the client for an ET cuff leak.": Evaluating for an ET cuff leak is relevant but is not the most urgent action in this situation. The high-pressure alarm indicates an immediate problem that requires rapid intervention, such as manual ventilation, to stabilize the client.

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