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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. A diet high in potassium: A high-potassium diet can actually help lower blood pressure and is often recommended for hypertensive patients.

B. Taking benazepril: Benazepril is an ACE inhibitor used to treat hypertension, so it is not a risk factor for developing high blood pressure.

C. Obstructive sleep apnea (OSA): OSA is a significant risk factor for the development of hypertension. The repeated episodes of apnea during sleep can lead to increased sympathetic nervous system activity and elevated blood pressure.

D. High-density lipoprotein (HDL) level of 70 mg/dL: A high HDL level is generally considered protective against cardiovascular diseases, including hypertension.

A. Assist with passive range of motion exercises. B. Monitor the pulse oximetry every two hours. C. Encourage 1 liter of fluid intake in 24 hours. D. Encourage the client to focus efforts on discharge.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

Correct Answer is C

Explanation

A nurse is caring for a client with a history of advanced HIV who was admitted with a diagnosis of Pneumocystis jirovecci pneumonia. The nurse should prioritize which nursing care goal?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

A nurse is caring for a client who has developed Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) from cancer. Which of the following nursing interventions should be included in the client's plan of care? (Select all that apply.)

A student nurse is learning about client safety. The student nurse should recognize that which of the following is true regarding client safety and prevention of harm?

The nurses in the emergency department have presented the nurse leader with a suggestion for streamlining the triage process, cutting down on wait times. Which of the following qualities does the leader specifically need, to implement the suggestion?

A nurse is caring for a client diagnosed with HIV and receiving antiretroviral therapy. The nurse should assess for which potential adverse effects of long-term antiretroviral therapy?

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?

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client that which of the following beverages can trigger an attack?

A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?