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 A
Explanation
A. Fluctuation of the fluid level within the water seal chamber
Fluctuation of the fluid level within the water seal chamber indicates that the chest tube is functioning properly. This fluctuation is a normal finding and reflects the movement of air in and out of the pleural space during the respiratory cycle. As the patient inhales, the fluid level drops, and as they exhale, it rises.
B. Equal amounts of fluid drainage in each collection chamber:
Equal amounts of drainage may suggest a problem with the drainage system or that the chest tube is not effectively draining air or fluid from the pleural space.
C. Continuous bubbling within the water seal chamber:
Continuous bubbling in the water seal chamber may indicate an air leak, which is not a normal finding. It should be investigated further.
D. Absence of fluid in the drainage tubing:
The absence of fluid in the drainage tubing may suggest that the chest tube is not effectively draining fluid from the pleural space or that there is a blockage in the system. It requires assessment and intervention.
Correct Answer is B
Explanation
A. “Check your oxygen equipment once each week.”
Checking the oxygen equipment once a week is insufficient. The equipment should be regularly inspected for safety, including tubing, connections, and the condition of the oxygen concentrator or tank.
B. “Do not adjust the oxygen flow rate.”
The nurse should include in the teaching that the client should not adjust the oxygen flow rate without consulting their healthcare provider. Adjusting the oxygen flow rate without proper guidance can lead to inappropriate oxygen delivery, which may be harmful.
C. “Store unused oxygen tanks horizontally.”
Oxygen tanks should be stored in an upright position to prevent damage to the tank valve. Storing them horizontally can increase the risk of leaks or damage.
D. “Keep wool blankets on your bed.”
Wool blankets and other items that generate static electricity should be avoided near oxygen equipment, as they can increase the risk of fire. The client should be advised to use non-static bedding and clothing.
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