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","B","C","D","E"]

Explanation

A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.

B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.

C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.

D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.

E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.

A. Client develops petechiae on the arms, legs, and abdomen. B. Health care provider orders Coumadin 2.5 mg P.O. to begin today. C. Client develops slight ecchymosis at the venipuncture site. D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds.

Correct Answer is D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is noted to have type I hypersensitivity reaction with a systemic response. Which clinical manifestations should the nurse anticipate? (Select all that apply).

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

Explanation

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

Correct Answer is D

Explanation

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