A nurse is caring for a client receiving mechanical ventilation. The nurse should prioritize which action associated with neuromuscular blockade use?

Respond to ventilator alarms.

Report the absence of spontaneous respirations.

Provide passive range-of-motion exercises.

Encourage the client to attempt to breathe on their own.

Answer and Explanation

The Correct Answer is C

A. Respond to ventilator alarms: While it is crucial to respond to ventilator alarms promptly to ensure the client’s safety and adequate ventilation, this action is not the highest priority in relation to the use of neuromuscular blockers. The use of neuromuscular blockade requires a broader focus on the patient's overall care and safety.
B. Report the absence of spontaneous respirations: Reporting the absence of spontaneous respirations is important, as neuromuscular blockers can cause paralysis of the respiratory muscles. However, the focus should be on maintaining the client's safety and comfort while they are on mechanical ventilation, rather than just reporting findings.
C. Provide passive range-of-motion exercises: This is the priority action when caring for a client receiving neuromuscular blockers. Since the client cannot move voluntarily due to the effects of the neuromuscular blockade, passive range-of-motion exercises are essential to prevent complications such as contractures and muscle atrophy. This intervention helps maintain joint mobility and circulation, which is critical in patients who are mechanically ventilated for an extended period.
D. Encourage the client to attempt to breathe on their own: Encouraging the client to breathe on their own is not appropriate when they are receiving neuromuscular blockade, as their respiratory muscles are paralyzed. Instead, the focus should be on ensuring that the mechanical ventilation settings are adequate to provide proper oxygenation and ventilation while the client cannot initiate breaths independently. This action could lead to respiratory distress if attempted while under neuromuscular blockade.

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 D

Explanation

A. Reports routinely list the identification number of any equipment involved: This practice is appropriate and helps in tracking any equipment-related issues. Including identification numbers can assist in identifying problems with specific devices or tools and does not represent a problem that needs to be reported.
B. Reports routinely include the client's hospital number: Including the client's hospital number in reports is standard practice for maintaining accurate records and ensuring proper tracking of incidents related to specific patients. This does not indicate a problem and is essential for accountability in healthcare reporting.
C. Reports routinely are completed within 24 hr after the incident: Timeliness in completing incident reports is important, and completing them within 24 hours is a best practice. This indicates a proactive approach to addressing incidents and does not represent a problem that needs to be reported to the risk manager.
D. Reports routinely omit the names of witnesses to the occurrence: This is a significant issue that should be reported to the risk manager. Witnesses can provide valuable information about the circumstances surrounding an incident, and their names should be documented for follow-up and investigation. Omitting this information could hinder the thoroughness of the incident review and the organization’s ability to address and prevent future occurrences effectively.

Correct Answer is []

Explanation

Assess for subcutaneous emphysema: Assessing for subcutaneous emphysema is crucial because it can indicate that air is escaping into the subcutaneous tissue, often resulting from a significant air leak. Early detection of subcutaneous emphysema allows for timely intervention, which is essential to manage the complication effectively and prevent further respiratory compromise.
Check the drainage system and tubing: Checking the drainage system and tubing is important to ensure that the chest tube and drainage system are functioning correctly. This includes identifying any kinks, disconnections, or leaks in the tubing that could contribute to the air leak. Ensuring the integrity of the drainage system is vital for effective management of the client’s respiratory condition and for restoring proper lung expansion.
Obtain blood cultures: This action is not indicated in this scenario unless there are signs of infection. The client’s symptoms do not suggest an infection requiring cultures at this time. Blood cultures would be more appropriate if there were signs of systemic infection, such as fever or elevated white blood cell count.
Administer prescribed blood products: This action is also not appropriate unless there is evidence of significant bleeding or anemia. The client’s hemoglobin levels are within normal limits, so this intervention is not necessary.
Observe surgical dressing: While important for monitoring the integrity of the surgical site, this action is not the priority when assessing for an air leak. Observing the dressing can help identify signs of drainage or infection but should follow the assessment for subcutaneous emphysema and the examination of the drainage system.
Respiratory status: Monitoring the client's respiratory status is crucial for assessing lung function and detecting any changes in breathing patterns, oxygen saturation, or the presence of respiratory distress. Given the client's recent thoracotomy, careful observation can help identify complications early.
Chest tube drainage: Assessing chest tube drainage is important to monitor the amount and type of fluid draining from the chest, as well as to identify any changes that may indicate bleeding or other complications. The 50 mL of sanguineous drainage noted since 0700 should be tracked to ensure it remains within acceptable limits and does not indicate excessive bleeding.
Client's ability to perform lung expansion exercises: While important for overall respiratory health, monitoring the client’s ability to perform lung expansion exercises is not as critical in the context of an acute air leak. However, encouraging lung expansion exercises can help prevent complications such as atelectasis.
Sputum: Monitoring sputum can provide information about respiratory status and potential infections. In this case, assessing sputum may be relevant but is secondary to monitoring respiratory status and chest tube drainage.
Blood pressure: Blood pressure is important to monitor but is not the primary focus in the context of chest tube management and respiratory issues. Monitoring blood pressure can provide information about the client’s overall hemodynamic stability but is not directly related to assessing the air leak.
Bleeding: While the client has some sanguineous drainage, the amount (50 mL) is not excessive, and hemoglobin levels are within normal limits. There are no signs of significant hemorrhage, making bleeding a less likely primary condition.
Pulmonary edema: Pulmonary edema typically presents with symptoms such as dyspnea, cough with frothy sputum, and hypoxia. The client's symptoms and findings do not support a diagnosis of pulmonary edema, which is more commonly associated with heart failure.
Pneumonia: While pneumonia can present with respiratory distress and abnormal lung sounds, the absence of fever and the clear sputum do not strongly indicate this condition in the current scenario. The findings are more consistent with an air leak.
Air leak: The presence of tidaling in the water seal chamber along with continuous bubbling in the chest tube drainage system suggests an air leak. Continuous bubbling indicates that air is escaping into the pleural space, which can compromise lung expansion and lead to respiratory complications. This situation necessitates immediate attention to prevent further respiratory distress.

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 receiving mechanical ventilation. The nurse should prioritize which action associated with neuromuscular blockade use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing event reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

A 65-year-old client with a history of diabetes mellitus was admitted to the hospital for a scheduled knee replacement surgery. During the postoperative period, the client developed a surgical site infection that required prolonged antibiotic therapy and wound care. This event is categorized as:

A clinic nurse is preparing to teach student nurses about care of clients with viral pharyngitis. Which information should the nurse include in the teaching plan? Select all that apply.

A nurse is searching for a new job. Which of the following is a good recommendation for a nurse who is searching for a job using the internet?

A college health nurse interprets the peak expiratory flow rate for student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

A new graduate nurse is about to go on their first job interview. Which of the following is a good recommendation for the new graduate nurse?

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?