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

Report the absence of spontaneous respirations.

Encourage the patient to attempt to breathe on their own.

Provide passive range-of-motion exercises.

Respond to ventilator alarms.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.

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Correct Answer is C

Explanation

Choice A rationale
Ambulation is a general measure that can help improve overall lung function by promoting deep breathing, coughing, and mobilization of secretions. However, it is not the primary measure to prevent atelectasis.
Choice B rationale
Oxygen therapy is used to treat hypoxia, which can be a result of atelectasis. However, it does not directly prevent the development of atelectasis.
Choice C rationale
Incentive spirometry is a first-line measure to prevent atelectasis. It encourages deep breathing, which helps keep the alveoli inflated and can prevent them from collapsing, thus preventing atelectasis.
Choice D rationale
Increasing oral fluid intake can help to thin secretions, making them easier to mobilize. However, it is not the primary measure to prevent atelectasis.

A. Intermittent oxygen use. B. Clubbing of fingers. C. Pursed-lip breathing. D. Prolonged exhalation. E. Dyspnea on exertion.

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

Explanation

Choice A rationale
Intermittent oxygen use is common in clients with COPD, especially during activities that increase oxygen demand or during acute exacerbations.
Choice B rationale
Clubbing of fingers is a sign of chronic hypoxia, which can occur in advanced COPD78.
Choice C rationale
Pursed-lip breathing is a technique often used by clients with COPD to improve exhalation and reduce breathlessness.
Choice D rationale
Prolonged exhalation is a common finding in COPD due to airway obstruction and air trapping.
Choice E rationale
Dyspnea on exertion is a common symptom in COPD due to decreased lung function and increased work of breathing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) who is being evaluated for a lung transplant. What findings should a nurse expect when performing an initial physical assessment on a client diagnosed with COPD? Select all that apply.

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

Explanation

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