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    Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph
    Select All That Apply

    A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

    Explanation & Rationale

    A. Check for a disconnection in the ventilator tubing: A disconnection causes low-pressure alarms, not high-pressure alarms. B. Check for a kink in the ventilator tubing: Kinked or obstructed tubing increases resistance to airflow, causing high-pressure alarms. C. Suction the ET to remove secretions: Secretions in the airway increase airway resistance and pressure, leading to high-pressure alarms. D. Assess the ET for a cuff leak: A cuff leak results in low-pressure alarms due to air escaping from the system. E. Verify the placement of the ET: Malposition usually leads to decreased airflow or low-pressure alarms.

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