NCLEX Practice Test

What should a nurse do first upon detecting a low-pressure limit alarm on a ventilator?

1. Check for any tubing disconnects

2. Change the ventilator settings

3. Increase the oxygen supply

4. Record the ventilator readings

The correct answer is: Check for any tubing disconnects

When a nurse detects a low-pressure limit alarm on a ventilator, the priority action is to check for any tubing disconnects. This is critical because a low-pressure alarm indicates that there is insufficient pressure in the ventilatory circuit, which can lead to inadequate ventilation of the patient. The most common reason for this alarm is a disconnection in the ventilator tubing or the patient’s airway, which can cause a significant drop in pressure. By checking for any tubing disconnects first, the nurse ensures that the patient remains connected to the ventilator properly, allowing for effective gas exchange and preventing complications such as hypoxia. Immediate attention to this potential issue can stabilize the patient's condition and maintain adequate ventilation. Responding in other ways, such as changing ventilator settings, increasing the oxygen supply, or recording readings, may not address the underlying cause of the alarm promptly. These actions can be taken later, but ensuring that the ventilatory connection is intact takes precedence to safeguard the patient's respiratory status.