Question

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

a. Obtain ABGs
b. Administer Propofol to the client.
c. Instruct the client to allow the machine to breathe for them.
d. Disconnect the machine and manually ventilate the client.

Answer 1

When the high-pressure alarm sounds on a mechanical ventilator, the nurse should first ensure that the client's airway is not compromised before taking other actions such as checking the equipment, obtaining ABGs, or administering sedatives.

Step-by-step explanation:

The first action the nurse should take when a high-pressure alarm sounds on a mechanical ventilator is to assess the situation and ensure the client's airway is not compromised. The alarm may indicate a problem such as an obstruction, a kink in the tubing, or increased airway resistance, which could be due to the client's anxiety and resistance against the ventilator. While obtaining arterial blood gases (ABGs), administering sedatives like Propofol, and advising the patient to relax may all be important, ensuring the airway is patent and the client is being ventilated properly is critical. The immediate response should typically be to check for and correct any disconnections or blockages in the ventilator circuit, and if necessary, to manually ventilate the client using a resuscitation bag (called bag-valve-mask or BVM ventilation) until the issue is resolved.