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 B
Explanation
A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.
B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.
C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.
D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.
Correct Answer is D
Explanation
A. Constipation: Constipation is not a common adverse effect of Atenolol, which is a beta- blocker.
B. Cough: Cough is more commonly associated with ACE inhibitors rather than beta-blockers like Atenolol.
C. Tremor: Tremor is not typically an adverse effect of Atenolol; beta-blockers can actually be used to treat essential tremors.
D. Bradycardia: Atenolol, as a beta-blocker, can slow the heart rate, leading to bradycardia, which is a well-documented adverse effect.
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