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.

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

Explanation

A. Clubbing of the fingers: This finding is often associated with chronic respiratory conditions, including emphysema, due to prolonged hypoxia. The chronic low oxygen levels can lead to changes in the nail beds, resulting in clubbing as the body attempts to compensate for the decreased oxygenation. Therefore, clubbing is a common assessment finding in clients with emphysema.
B. Bradycardia: Emphysema typically does not cause bradycardia; instead, clients may experience tachycardia due to increased respiratory effort and oxygen demand. While individual variations can occur, bradycardia is not a standard finding in clients with emphysema, making this option less likely to be present.
C. Barrel chest: This is a common physical assessment finding in clients with emphysema. The chronic overinflation of the lungs leads to a characteristic increase in the anteroposterior diameter of the chest, resulting in a barrel-shaped appearance. This occurs as the diaphragm becomes flattened and the rib cage is expanded from prolonged air trapping.
D. Dyspnea: Shortness of breath, or dyspnea, is a hallmark symptom of emphysema. As the disease progresses, clients may experience increased difficulty in breathing, especially during exertion, due to the destruction of alveoli and reduced lung elasticity. This finding is expected and significant in the assessment of a client with emphysema.
E. Deep respirations: In emphysema, clients often exhibit shallow, rapid breathing patterns rather than deep respirations. The loss of elasticity in the lungs leads to difficulty in full lung expansion, which can result in a more shallow and increased respiratory rate. Therefore, deep respirations are not a typical finding in clients with emphysema.

A. The student's asthma is not well controlled. B. The nurse should obtain a second expiratory flow rate. C. The student needs to go to the hospital. D. The student should use his quick-relief inhaler. E. The student's peak flow is 50% to 80% of his best peak flow.

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

Explanation

A. The student's asthma is not well controlled: Being in the yellow zone indicates that the student's asthma is not well controlled and that their peak expiratory flow rate (PEFR) is lower than usual. This is a crucial point for the nurse to recognize, as it suggests that the student may need to adjust their management plan to prevent an exacerbation.
B. The nurse should obtain a second expiratory flow rate: While it can be helpful to reassess peak flow rates, it is not always necessary unless there is a concern about the accuracy of the initial measurement. The initial yellow zone result provides sufficient information for the nurse to take appropriate action regarding the student's asthma management.
C. The student needs to go to the hospital: Being in the yellow zone does not automatically require hospitalization. The yellow zone typically indicates that the student is experiencing some worsening of asthma symptoms but can often be managed at home with appropriate interventions. Hospitalization is usually reserved for the red zone, where severe symptoms or a significant decrease in peak flow occurs.
D. The student should use his quick-relief inhaler: This is an appropriate action for a student in the yellow zone. The yellow zone often indicates the need for the use of a quick-relief inhaler to alleviate symptoms and improve airflow. The nurse should advise the student to use their inhaler as per their asthma action plan.
E. The student's peak flow is 50% to 80% of his best peak flow: This statement accurately describes the yellow zone, where the peak flow is between 50% and 80% of the student's personal best. This information is essential for determining the appropriate response to the current asthma status and guides the nurse's actions.

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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 caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

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

Explanation

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.)

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

Explanation

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