HESI Registered Nurse EXIT Practice Exam

If the high-pressure alarm goes off on a mechanical ventilator, what should the nurse do first?

1. Disconnect the client from the ventilator and use a manual resuscitation bag

2. Perform a quick assessment of the client's condition

3. Call the respiratory therapist for help

4. Press the alarm re-set button on the ventilator

The correct answer is: Perform a quick assessment of the client's condition

When a high-pressure alarm on a mechanical ventilator goes off, the first action is to perform a quick assessment of the client's condition. This step is crucial because the high-pressure alarm often indicates a problem that could affect the patient's safety and status, such as increased resistance in the airway, an obstructed endotracheal tube, or a pneumothorax. By quickly assessing the client, the nurse can determine if the patient is in respiratory distress, indicate the need for immediate intervention, and identify any changes in vital signs or consciousness. This initial assessment is essential to prioritize the patient's needs effectively and guide subsequent actions, such as whether it is necessary to disconnect the patient from the ventilator or call for additional support. Taking immediate action based on the client's assessment allows for prompt identification of the underlying issue, which can often be resolved without needing to disconnect the patient from the ventilator or simply disabling the alarm.