The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply.

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11ecbb05_cb00_0809_b433_c1ffb9f315e1_MD0009_00 Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: Excessive secretions: Obstruct the airway, increasing resistance (Option D) Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance (Options A and E) (Options B and C) Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm. Educational objective: When the mechanical ventilator high-pressure limit alarm sounds, the nurse should assess for causes of increased airway resistance in the client (eg, bronchospasm), artificial airway (eg, excessive secretions, biting the endotracheal tube), and/or ventilator system (eg, kinked tubing), as well as for causes of decreased lung compliance (eg, pneumothorax).

The Nurse Caring for a Client with Pulmonary Edema Responds