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 B

Explanation

Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.

A. Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises. B. Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage. C. Potential Condition: Pulmonary edema. D. Potential Condition: Pneumonia.

Correct Answer is B

Explanation

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

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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 patient with lung cancer confides in the nurse, expressing fear about the disease and guilt for smoking in the past. Which response from the nurse would be most appropriate?

Correct Answer is B

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

Explanation

A nurse on a quality control committee is evaluating the effectiveness of recently implemented measures aimed at reducing medication errors. Which methods should the nurse use to evaluate the success of the changes?

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