A nurse is caring for a patient on mechanical ventilation wh… | 마이메르시 MyMerci
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Critical Care
문제

A nurse is caring for a patient on mechanical ventilation who suddenly develops high peak inspiratory pressures and decreased tidal volumes. The ventilator alarm is sounding. What is the nurse's first priority action?

해설
High peak inspiratory pressures with decreased tidal volumes indicate airway obstruction or decreased compliance. The nurse's first priority is to assess airway patency and breath sounds to identify the cause and ensure patient safety before intervening.
같은 주제 다음 문제A nurse is caring for a patient on mechanical ventilation who suddenly develops increased …

심화 해설

Clinical Judgment This question tests prioritization and emergency response. The occurrence of high peak inspiratory pressure and decreased tidal volume in a patient on mechanical ventilation is an immediate danger signal: Notify HCP! This suggests various life-threatening causes such as airway obstruction, pneumothorax, or bronchospasm. The nurse's first priority is always patient assessment. Manipulating equipment or calling others without identifying the cause is not appropriate. According to the ABC (Airway, Breathing, Circulation) principle, checking airway patency and breath sounds is the very first thing to do. Memory Tip: Do Only After Assessment (DOAA). All interventions must be performed after assessment. Especially in a "ventilator alarm" situation, remember to Assess the Patient, Not the Machine (APNM). KR vs US: In Korea, the role of respiratory therapists may be limited, so nurses might handle more technical troubleshooting. However, the US NCLEX emphasizes the nurse's independent judgment and initial assessment skills. When a ventilator problem occurs, even by US standards, checking the patient's condition should precede calling the respiratory therapist.

임상 시나리오

Clinical Practice Guide When a high pressure alarm sounds in a mechanically ventilated patient, a systematic approach follows the DOPE mnemonic:
Displacement (tube malposition: endobronchial intubation, etc.)
Obstruction (blockage: secretions, kinked tube)
Pneumothorax
Equipment (equipment malfunction)
The nurse should assess starting with the patient (evaluating D, O, P first) and then move to the equipment (E). Caution: In SATA (Select All That Apply) questions about "ventilator alarms," the option "turn off the ventilator alarm" can never be the correct answer. Alarms are safety devices, so ignoring or silencing them is not standard nursing practice.

핵심 개념

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