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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "When the doctor comes to see you, we can talk about whether you will need a transplant." This response acknowledges the client's concerns and opens the door for further discussion with the healthcare provider about the client's prognosis and potential need for a kidney transplant. It provides an opportunity for the client to receive accurate information from the appropriate healthcare professional.

B. "Kidney transplantation is likely, and it would be a good idea to start talking to family members." This response may cause unnecessary anxiety and speculation for the client without

confirmation from the healthcare provider. It is important to provide information based on the client's specific situation and medical assessment.

C. "No, don't think that. You're going to be fine in a few weeks." This response provides false reassurance and does not address the client's concerns or the potential seriousness of acute kidney injury. It is essential to provide honest and accurate information to the client.

D. "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." While acute kidney injury can sometimes be reversible with prompt and appropriate treatment, it is not always the case. Additionally, it does not address the potential need for a kidney transplant, which depends on the severity and underlying cause of the kidney injury.

A. Elevate the head of the bed 30 to 45 degrees. B. Perform hand hygiene before touching the ventilator tubing. C. Refrain from suctioning the client. D. Provide mouth care every 2-4 hours. E. Perform hand hygiene before touching the client.

Correct Answer is ["A","B","D","E"]

Explanation

A. Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B. Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C. Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D. Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E. Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

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A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client admitted with a diagnosis of acute kidney injury. The client asks the nurse, "Are my kidneys failing and will I need a kidney transplant?" The nurse should respond to the client with which of the following statements?

Correct Answer is A

Explanation

A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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