Saunders Respiratory Practice

What should the nurse do first when the high-pressure alarm sounds on a ventilator connected to an endotracheal tube?

1. Administer medication

2. Adjust the ventilator settings

3. Suction the client

4. Assess the vital signs

The correct answer is: Suction the client

When a high-pressure alarm sounds on a ventilator connected to an endotracheal tube, the first action a nurse should take is to suction the client. This is important because a high-pressure alarm often indicates that there is increased resistance in the airway, which can be caused by factors such as secretions, mucus plug, or even a kink in the endotracheal tube. By suctioning the client, the nurse can clear any obstructions that may be causing the elevated pressure, allowing for better ventilation and reducing the risk of further complications. While assessing vital signs or adjusting ventilator settings might be necessary afterward, addressing potential airway obstructions is the immediate priority. Administering medication could be relevant in the context of managing underlying issues, but it does not directly address the cause of the high-pressure alarm in this scenario. Therefore, suctioning is the most appropriate first response to ensure the airway is clear and the patient can breathe effectively.