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 B

Explanation

A. Assist with passive range of motion exercises: While promoting mobility is important for overall well-being, it may not be the priority in a client with Pneumocystis jirovecii pneumonia, which requires respiratory support and oxygenation.

B. Monitor the pulse oximetry every two hours: Monitoring oxygen saturation is crucial in clients with Pneumocystis jirovecii pneumonia to assess respiratory status and the effectiveness of treatment. Hypoxemia is a common complication and requires prompt intervention.

C. Encourage 1 liter of fluid intake in 24 hours: Encouraging adequate fluid intake is important for hydration, but it may not be the priority over monitoring respiratory status in a client with pneumonia.

D. Encourage the client to focus efforts on discharge: Discharge planning is important but should not take precedence over immediate nursing care priorities such as respiratory assessment and monitoring.

A. GI intolerance and neutropenia B. T-cell count of 500 and diarrhea C. Anorexia and constipation D. Bone demineralization and thrush

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.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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