A patient with acute respiratory distress syndrome is receiving a paralyzing agent. With a Train-of-four (TOF) assessment, the patient’s thumb twitches 3 times. How would the nurse interpret this response?
The patient’s paralysing agent dose in adequate, but needs to be given more often
The patients paralyzing agent dose is too low and needs to be increased
The patient’s paralyzing agent dose in appropriate and does not need to be changed
The patients paralyzing agent dose is too high and needs to be reduced
The Correct Answer is A
A. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.
B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.
C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.
D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Close the fire doors on the unit:
Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.
B. Use a fire extinguisher to put out the fire:
While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.
C. Move any clients in the immediate vicinity:
Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire:
- Rescue anyone in immediate danger.
- Alarm: Activate the fire alarm.
- Contain the fire by closing doors.
- Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.
D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.
Correct Answer is C
Explanation
A. Reduces inflammation:
This action is more characteristic of anti-inflammatory medications, such as corticosteroids. Expectorants, however, do not primarily reduce inflammation.
B. Dries mucous membranes:
This action is more characteristic of antihistamines or decongestants, which may help reduce nasal congestion by drying mucous membranes. Expectorants have the opposite effect; they promote the thinning of mucus.
C. Stimulates secretions
An expectorant is a type of medication that works by promoting the clearance of mucus from the respiratory tract. It does so by thinning and loosening mucus, making it easier for the patient to cough up and expel. Expectorants help in facilitating the removal of excessive mucus and can be useful in conditions where there is a productive cough associated with excessive mucus production.
D. Suppresses the urge to cough:
This action is associated with antitussive medications, which are cough suppressants. Expectorants, on the other hand, stimulate the removal of mucus and do not suppress the urge to cough
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