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
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.

A. Reports routinely list the identification number of any equipment involved. B. Reports routinely omit the names of witnesses to the occurrence. C. Reports routinely are completed within 24 hr after the incident. D. Reports routinely include the client’s hospital number.

Correct Answer is B

Explanation

Choice A rationale
Reports routinely listing the identification number of any equipment involved is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the equipment involved in the incident.
Choice B rationale
Reports routinely omitting the names of witnesses to the occurrence is a problem that should be reported to the risk manager. Witnesses can provide crucial information about the incident, and their statements can help in understanding the sequence of events and identifying the root cause of the incident.
Choice C rationale
Reports being completed within 24 hours after the incident is not a problem. Timely reporting of incidents is crucial for accurate recall of events and immediate initiation of corrective actions.
Choice D rationale
Reports routinely including the client’s hospital number is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the patient involved in the incident.

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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

During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?

Correct Answer is C

Explanation

A nurse is reviewing incident 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 B

Explanation

A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.

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