.0000 Sprint 2:30 PM ihpedu.neolms.com International College of Health Sciences
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.0000 Sprint 2:30 PM ihpedu.neolms.com International College of Health Sciences 20 12 Instructions The weekly NCLEX question is designed to test your critical thinking ability to make sound clinical judgments and prepare you for the ATI Proctored exam and the NCLEX. The nurse cares for a client with an endotracheal tube and positive pressure mechanical ventilation. Which observation requires an IMMEDIATE intervention by the nurse? 1.The LPN/LVN report that the client's weight has increased 3lbs over 72 hours 2. The client gags and bites at the endotracheal tube 3. The endotracheal cuff pressure is 18mmhg 4. The LPN/LVN drains ventilator tubing condensation towards the endotracheal tube connection See discussion Contact English (US)>Explanation / Answer
The correct answer would be 2. the client gags and bites at the endotracheal tube this will alarm has a high-pressure alert and a nurse should intervene by putting the airway in the patient's mouth.
The first option would be incorrect because weight gain can indicate altered urinary pattern which can be due to renal dysfunction and require renal intervention rather than ventilator modification.
Option 3 is incorrect because the tracheal cuff size normally ranges between 18 to 20 mm of Hg.
Option 4 The ventilator tubing condensation can potentially cause ventilator acquired pneumonia.
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