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. The importance of adhering closely to the prescribed medication regimen. Tuberculosis requires strict adherence to a long-term antibiotic regimen, typically lasting 6 to 9 months, to prevent drug resistance, treatment failure, and disease relapse. Noncompliance can lead to multidrug-resistant TB (MDR-TB), which is more difficult to treat. Directly observed therapy (DOT) is often recommended to ensure adherence.
B. The client must remain in respiratory isolation until medication treatment ends. While respiratory isolation is essential for active TB, it is not required until the full course of treatment is completed. Isolation is typically maintained until the client has received at least two weeks of effective therapy, symptoms improve, and three consecutive sputum smears are negative for acid-fast bacilli (AFB).
C. The fact that the disease is self-limiting, but can take up to two years to resolve. TB is not self-limiting; without proper treatment, it can persist indefinitely, worsen, and become fatal. Standard treatment with first-line drugs such as isoniazid, rifampin, ethambutol, and pyrazinamide effectively eradicates the infection within 6 to 9 months in most cases.
D. The importance of participating in physical therapy to re-establish functional abilities. While TB can cause fatigue and weakness, physical therapy is not a primary focus of treatment. The priority is to eradicate the infection through strict medication adherence, as untreated TB can progress to severe pulmonary damage, systemic involvement, and complications.
Correct Answer is ["A","C","E"]
Explanation
A. Culturally incompetent caregivers. When healthcare providers lack cultural awareness, they may struggle to communicate effectively with patients from diverse backgrounds. This can lead to misunderstandings, decreased trust, and reduced adherence to treatment plans. Patients may feel unheard or disrespected if their cultural beliefs and preferences are not considered. Cultural competence training helps bridge communication gaps and improves patient-provider relationships.
B. Proper training in healthcare communication. Training in communication enhances a provider’s ability to listen actively, use clear language, and foster patient-centered interactions. It helps reduce medical errors, improve patient understanding, and enhance trust in healthcare providers. Since communication training strengthens interactions rather than hindering them, it is not considered a barrier. Well-trained providers can adapt their approach to meet the needs of each patient effectively.
C. Implicit bias. Unconscious biases can negatively affect how healthcare providers interact with patients, leading to disparities in care. Providers may unintentionally assume things about a patient based on stereotypes rather than their individual needs. This can cause miscommunication, lack of trust, and reluctance to seek care. Recognizing and addressing implicit bias is crucial for ensuring equitable and effective communication.
D. Excellent health literacy. High health literacy enables patients to understand medical information, follow treatment plans, and communicate effectively with providers. This reduces confusion, enhances decision-making, and improves health outcomes. Since excellent health literacy helps rather than hinders communication, it is not a barrier. Instead, it empowers patients to engage more actively in their care.
E. Lack of diversity. A lack of diversity in healthcare can result in communication barriers, as providers may be less familiar with different cultural perspectives and language needs. This can lead to misunderstandings, decreased patient satisfaction, and reduced quality of care. A diverse healthcare workforce fosters inclusivity, improves provider-patient communication, and promotes better health outcomes. Encouraging diversity ensures a more culturally competent and responsive healthcare system.
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