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 D

Explanation

A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.

B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.

C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.

D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.

A. "I will take my medication even if symptoms improve." B. "I will not have my hair dyed or relaxed unless I am in a period of remission." C. "I will sunbathe as often as possible to ensure I get enough vitamin D." D. "I will report any fever to my healthcare provider immediately."

Correct Answer is C

Explanation

A. "I will take my medication even if symptoms improve." This statement indicates understanding of the importance of medication compliance in managing SLE, as symptoms may improve but the disease may still be active.

B. "I will not have my hair dyed or relaxed unless I am in a period of remission." This statement shows awareness of avoiding potential triggers for disease flare-ups during active periods of SLE.

C. "I will sunbathe as often as possible to ensure I get enough vitamin D." Sun exposure can trigger or worsen SLE symptoms, and individuals with SLE are often advised to avoid excessive sun exposure and to use sun protection to minimize flare-ups.

D. "I will report any fever to my healthcare provider immediately." This statement demonstrates understanding of the importance of monitoring for signs of infection or disease flare-ups, which can be common in SLE.

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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?

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