Question

The high pressure alarm on the ventilator sounds, you enter the room, the client is Agitated Respiratory rate 40 Oxygen saturation is 81 % Blood pressure 98/44 mmHg breaths/min Sinus tachycardia 142 beats/min What action will you implement first? Underline and provide rationale for the selection Auscultate breath sounds Increase the FIO2 setting to 100% Check the ventilator settings and readouts Suction the ET tube after hyperoxygenating the client Your assessment data No breath sounds on right side with minimal expansion on inspiration ET tube position remains at 23-cm at the client's teeth What is your suspected problem for the client? Underline and provide rationale for the selection Oxvgenation r/t mechanical ventilation AEB inadvertent extubation Oxygenation r/t mechanical ventilation AEB tension pneumothorax Oxygenationr/t mechanical ventilation AEB ET tube displacement Oxygenation r/t mechanical ventilation AEB aspiration pneumonia

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Answer 1

The high pressure alarm on the ventilator sounds, you enter the room, the client is Agitated Respiratory rate 40 breaths/min Oxygen saturation is 81 % Blood pressure 98/44 mmHg Sinus tachycardia 142 beats/min What action will you implement first? Underline and provide rationale for the selection Auscultate breath sounds Increase the FIO2 setting to 100 % Check the ventilator settings and readouts Suction the ET tube after hyperoxygenating the client Assessing the patient is the first thing to do immediately after an alarm sounds. The respiratory complication can be assessed by observing the chest movement, carefully assessing the breath sounds, and respiratory effort of the patient. After assessing, as needed an appropriate action can be taken Your assessment data No breath sounds on right side with minimal expansion on inspiration ET tube position remains at 23-cm at the client's teeth What is your suspected problem for the client? Underline and provide rationale for the selection Oxygenation r/t mechanical ventilation AEB inadvertent extubation Oxygenation r/t mechanical ventilation AEB tension pneumothorax Oxygenation r/t mechanical ventilation AEB ET tube displacement Oxygenation r/t mechanical ventilation AEB aspiration pneumonia Pneumothorax collapsed lung occurs due to entering of the air into the hyperinflation of lungs. It causes reflection of the or S pleural cavity, which causes sounds, it does not cause The decreased or absence of breath sounds on right side with minimal expansion during inspiration suggest pneumothorax, which is possibly due to pressure trauma. The ET tube displacement remain intact in the given can also reduce the breath sounds, but it case

Reference:

Bartz, B. (2013). Prioritization, Delegation, and Assignment: Practice Exercises for the Ncl. Elsevier-Health Sciences Division.