A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?
Respond to ventilator alarms.
Report the absence of spontaneous respirations.
Encourage the client to take spontaneous breaths.
Place the call bell within reach.
The Correct Answer is B
A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.
B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.
C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.
D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. GI intolerance and neutropenia: Antiretroviral therapy can cause gastrointestinal intolerance, including nausea, vomiting, diarrhea, and abdominal pain. Neutropenia, a decrease in neutrophil count, can also occur as a side effect of some antiretroviral medications.
B. T-cell count of 500 and diarrhea: While diarrhea can be a side effect of antiretroviral therapy, a T-cell count of 500 is not necessarily an adverse effect and may indicate effective treatment.
C. Anorexia and constipation: Anorexia and constipation are not commonly associated with antiretroviral therapy. However, gastrointestinal side effects such as diarrhea are more common.
D. Bone demineralization and thrush: Bone demineralization (osteoporosis) can occur as a long- term complication of HIV infection and antiretroviral therapy, but it is not a direct adverse effect of antiretroviral medications. Thrush (oral candidiasis) can occur in HIV-infected individuals, but it is not specifically related to antiretroviral therapy.
Correct Answer is C
Explanation
A. Chemotherapy is only used for palliation: While chemotherapy can be used for palliative care to relieve symptoms and improve quality of life in advanced cancer, it is also used with curative intent in some cases, especially when cancer is diagnosed early or is responsive to chemotherapy.
B. Chemotherapy cures prostate cancer that has metastasized to the bone: Chemotherapy alone is generally not curative for prostate cancer that has metastasized to the bone. It may help slow disease progression, relieve symptoms, or prolong survival, but it is not typically curative on its own.
C. Chemotherapy is used in conjunction with other treatment modalities in this type of cancer: Chemotherapy is often used in combination with other treatment modalities such as hormone therapy, radiation therapy, or surgery in the management of prostate cancer with bone metastasis. The goal is to target cancer cells using multiple approaches to achieve the best possible outcome for the patient.
D. Chemotherapy makes the body fluid a biohazard: Chemotherapy drugs can be excreted in body fluids such as urine, saliva, and sweat, making them potentially hazardous. However, this statement does not specifically address the role of chemotherapy in the treatment of prostate cancer with bone metastasis.
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