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 D
Explanation
A. Grilled chicken, white rice, sliced peaches: While grilled chicken is a lean protein source, white rice is low in fiber and may not be the best choice for someone experiencing severe diarrhea. Sliced peaches are a good fruit choice, but the meal lacks sufficient fiber and other nutrients.
B. Spaghetti with tomato sauce, meatballs, and garlic bread: This meal contains high-fat and high-carbohydrate foods, which may exacerbate diarrhea. Tomato sauce can be acidic and irritating to the digestive system for some individuals.
C. Fried shrimp, cauliflower, yogurt with granola: Fried foods are high in fat and may worsen diarrhea. Cauliflower is a good vegetable choice, but yogurt with granola may not be well- tolerated if the client is lactose intolerant or sensitive to dairy products.
D. Grilled salmon, brown rice, broccoli: Grilled salmon provides lean protein and omega-3 fatty acids, which can be beneficial for overall health. Brown rice is higher in fiber compared to white rice and can help regulate bowel movements. Broccoli is a good source of fiber and essential nutrients. This meal is well-balanced and nutritious, making it a suitable choice for someone experiencing diarrhea.
Correct Answer is ["B","C","E"]
Explanation
A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.
B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.
C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.
D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.
E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.
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