6. What should alert a nurse to a possible problem with a client who is on a mechanical ventilator?
. Loud beeping when the respiratory therapist is suctioning the client.
. A client is using accessory muscles while on the ventilator.
. Bronchovesicular breath sounds are heard on auscultation.
. Water is collecting in the ventilator tubing.
Test-Taking Tip
Look for the option that describes a client in distress.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Therapeutic Procedures
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Answer 1 is incorrect because an alarm sounds whenever the client is disconnected or the pressure drops (as with suctioning). This alarm can be silenced. Answer 2 is correct because use of accessory muscles indicates the client has to work to breathe. Answer 3 is incorrect because bronchovesicular breath sounds are normal. Answer 4 is incorrect because water collects in the ventilator tube and requires periodic draining. Unless excessive in volume, or unless it pours into the client's endotracheal tube, it does not represent a client problem.