# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542621  
> language: ko  
> subject: 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?

## 보기

1. Assess the patient's airway patency and breath sounds immediately **✔ 정답**
2. Increase the tidal volume setting on the ventilator immediately
3. Suction the endotracheal tube immediately
4. Call the respiratory therapist immediately

**정답: 1**

## 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.

## 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: **D**o **O**nly **A**fter **A**ssessment (DOAA). All interventions must be performed after assessment. Especially in a "ventilator alarm" situation, remember to **A**ssess the **P**atient, **N**ot the **M**achine (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:

**D**isplacement (tube malposition: endobronchial intubation, etc.)

**O**bstruction (blockage: secretions, kinked tube)

**P**neumothorax

**E**quipment (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

- **Peak Inspiratory Pressure** — Peak inspiratory pressure. This is the maximum pressure required for the ventilator to push air into the patient's lungs. The normal range is typically below 20-30 cmH2O. Elevation indicates increased airway resistance or decreased lung compliance.
- **Tidal Volume** — Tidal volume. It is the amount of air that enters and leaves the lungs during one breath. A decrease during mechanical ventilation indicates that effective ventilation is not occurring.
- **Airway Patency** — Airway patency. The state in which the respiratory airway is open and unobstructed, allowing air to pass freely. It is the most basic and important element in the management of mechanically ventilated patients.
- **Ventilator-Associated Event** — Ventilator-associated events. This is a term that encompasses complications related to mechanical ventilation (e.g., pneumonia, pneumothorax). High-pressure alarms can be an early sign of such events.
- **DOPE Mnemonic** — A mnemonic for remembering the causes of high-pressure alarms in mechanical ventilation. It stands for Displacement (tube malposition), Obstruction (airway blockage), Pneumothorax, and Equipment (equipment issues).

## 같은 주제 문제

- [A nurse is caring for a patient on mechanical ventilation who suddenly develops increased …](https://mymerci.kr/pages/nclex_q.php?qn_id=542610)
- [A nurse is caring for a patient on mechanical ventilation with assist-control mode. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=542611)
- [A nurse is caring for a patient on mechanical ventilation with assist-control mode. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=542612)
- [A nurse is caring for a 65-year-old patient with COPD on mechanical ventilation who sudden…](https://mymerci.kr/pages/nclex_q.php?qn_id=542613)
- [A nurse is caring for a postoperative patient on mechanical ventilation who suddenly devel…](https://mymerci.kr/pages/nclex_q.php?qn_id=542614)
- [A nurse is caring for a patient on mechanical ventilation who suddenly develops high peak …](https://mymerci.kr/pages/nclex_q.php?qn_id=542615)
- [A nurse is caring for a postoperative patient who develops severe respiratory distress wit…](https://mymerci.kr/pages/nclex_q.php?qn_id=542616)
- [A patient on mechanical ventilation develops sudden onset of severe respiratory distress, …](https://mymerci.kr/pages/nclex_q.php?qn_id=542617)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._