A male client suffers acute respiratory distress syndrome as a consequence of shock. The client’s condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
A. Kinking of the ventilator tubing.
B. A disconnected ventilator tube.
C. An ET cuff leak.
D. A change in the oxygen concentration without resetting the oxygen level alarm.
Correct Answer: A. Kinking of the ventilator tubing
Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolism, mucus plugging, water in the tube, coughing or biting on the ET tube, and the client’s being out of breathing rhythm with the ventilator.
Option B: A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. The low-pressure alarm indicates a possible disconnection or mechanical ventilator malfunction.
Option C: The high peak pressure alarm indicates bronchospasm, retained secretions, obstruction of ET tube, atelectasis, acute respiratory distress syndrome (ARDS), or pneumothorax, among others.
Option D: Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm. Listen for alarms. Know the range in which the ventilator will set off the alarm and how to troubleshoot.
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