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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Efficiency in healthcare refers to the optimal use of resources to achieve the desired health outcomes. Reducing wait times in the emergency department is an example of improving efficiency, as it involves streamlining processes to provide timely care.
Choice B rationale
Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters is more related to the safety and effectiveness domains of healthcare quality.
Choice C rationale
Using an interpreter for patients who do not speak the healthcare provider’s language is related to the equity and patient-centeredness domains of healthcare quality.
Choice D rationale
Opening and utilizing supplies that are necessary for the task is a basic requirement in healthcare, but it does not specifically relate to the efficiency domain of healthcare quality.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s actions are an example of Quality Improvement. Quality Improvement involves systematic actions that lead to measurable improvement in health care services and the health status of targeted patient groups. In this case, the nurse identified a problem (increase in pressure injuries), collected data (documented findings), and implemented a change (new policy for consistent use of a pressure injury risk assessment scale) to improve patient outcomes.
Choice B rationale
While collaboration was part of the process (the nurse collaborated with the manager), the overall actions taken represent a Quality Improvement process.
Choice C rationale
Case Management typically involves coordinating the care and services of select patient populations, such as those with chronic illnesses or complex health needs. It does not directly apply to this scenario.
Choice D rationale
Advocacy involves supporting or promoting the interests of others, such as patients or colleagues. Although the nurse’s actions could be seen as advocating for the patients’ well- being, the term that best characterizes these actions is Quality Improvement.
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