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 C
Explanation
A. Reports of joint pain: Joint pain is more indicative of musculoskeletal issues rather than chronic renal disease. While joint pain can occur in some types of kidney disease, progressive edema is a more specific symptom.
B. Increase in appetite: An increase in appetite is not typically associated with chronic renal disease. Instead, clients with kidney disease may experience a decrease in appetite due to various factors such as nausea, vomiting, and changes in taste.
C. Progressive edema: Progressive edema, especially in the lower extremities and around the eyes (periorbital edema), can be a significant indicator of declining kidney function. It results from fluid retention due to impaired kidney filtration.
D. Recent increase in thirst: While increased thirst can be a symptom of chronic renal disease, it is not as specific as progressive edema. Increased thirst may occur due to other conditions or factors such as diabetes mellitus or dehydration.
Correct Answer is C
Explanation
A. Incompetence: Incompetence refers to a lack of skill or ability to perform a task effectively. It is not a desirable quality in a leader and would hinder rather than facilitate the implementation of new processes.
B. Integrity: Integrity is essential for a leader but is not specifically related to implementing new suggestions or initiatives. Integrity involves honesty, ethics, and adherence to moral principles.
C. Initiative: Initiative refers to the ability to take action and drive forward new ideas or projects. A leader with initiative is proactive and encourages innovation and improvement within the organization. Implementing suggestions for streamlining processes requires initiative to initiate change and drive improvement.
D. Fear: Fear is not a desirable quality in a leader when it comes to implementing changes or new initiatives. Leaders need to be confident, decisive, and willing to take calculated risks to drive positive change and improvement. Fear can inhibit innovation and progress.
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