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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Set ground rules: This step involves establishing guidelines for the discussion to ensure that all participants feel respected and heard. By inviting each staff member to speak in turn and asking them to listen respectfully without making personal or professional remarks, the nurse manager is creating a safe and structured environment for open communication. Setting ground rules is crucial for facilitating a productive dialogue and minimizing conflict during negotiations.
B. Perform an opening move: This refers to the initial statement or action taken to start the negotiation process. While the nurse manager is initiating the meeting, the emphasis on respectful communication and turn-taking indicates that the focus is more on establishing an effective communication framework rather than simply making an opening statement.
C. Continue the negotiation: This step implies that the negotiation is already underway and is focused on maintaining momentum in the discussion. However, the scenario describes the nurse manager taking proactive steps to set the stage for the negotiation rather than continuing an existing conversation.
D. Clarify the problem: While it is important to identify and clarify the staffing issues and tardiness, the nurse manager's actions are more about creating an environment for discussion rather than explicitly defining the problem at this stage. Setting ground rules is a foundational step that supports problem clarification by fostering respectful dialogue among participants.
Correct Answer is B
Explanation
A. Supportive feedback: This term refers to positive, constructive input that aims to help a colleague improve their practice or decision-making. Nurse Taylor's behavior does not reflect supportive feedback; rather, it is negative and undermining, contributing to a hostile work environment.
B. Lateral violence: This term describes aggressive or bullying behavior exhibited by colleagues at the same hierarchical level. Nurse Taylor's sarcastic remarks and belittling comments toward Nurse Jordan are clear examples of lateral violence, as they create a toxic atmosphere and negatively impact team dynamics. This behavior can lead to increased stress and decreased morale among team members.
C. Workplace violence: While Nurse Taylor's behavior can be considered a form of workplace violence in a broader sense, it is more specifically classified as lateral violence. Workplace violence generally encompasses physical threats or harm, while lateral violence focuses on verbal and emotional abuse among coworkers.
D. Constructive criticism: Constructive criticism involves providing feedback aimed at improving performance while maintaining respect and professionalism. Nurse Taylor's sarcastic remarks do not meet this definition, as they are not aimed at helping Nurse Jordan but rather serve to belittle and undermine her. Therefore, this behavior is not constructive and instead falls into the category of lateral violence.
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