Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?
The patient has no cough reflex when suctioned.
The patient's oxygen saturation is 90% to 93%
The patient does not respond to voice.
No sedative is ordered for the patient
The Correct Answer is D
D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.
A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.
B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.
C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Administering furosemide, a loop diuretic, to a patient in septic shock with low urine output could exacerbate hypovolemia and worsen organ perfusion. It could further reduce preload, exacerbating hypotension, and impairing cardiac output. Loop diuretics are typically contraindicated in hypovolemic shock.
A. Corticosteroids such as hydrocortisone can help improve vascular tone and responsiveness to vasopressors. Given the patient's clinical presentation and lack of response to initial fluid resuscitation, administering hydrocortisone is appropriate.
C. Increasing the fluid infusion rate can help restore intravascular volume and improve organ perfusion. However, caution should be exercised to avoid fluid overload and pulmonary edema.
D .Norepinephrine is a vasopressor commonly used to increase systemic vascular resistance and improve blood pressure in septic shock. It helps maintain perfusion pressure to vital organs, thereby supporting organ function.
Correct Answer is B
Explanation
B. A client who is postoperative with shallow respirations at a rate of 9/min is likely not adequately eliminating carbon dioxide from their body due to hypoventilation. This retention of carbon dioxide can lead to an increase in the partial pressure of CO2 in the blood, causing an acidotic state.
A. Metabolic acidosis results from an accumulation of acids in the body or a loss of bicarbonate. Hypoventilation leading to respiratory acidosis does not directly cause metabolic acidosis.
C. Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased arterial carbon dioxide levels (hypocapnia) and an increase in pH. Shallow respirations and decreased respiratory rate are more consistent with hypoventilation and respiratory acidosis rather than hyperventilation and respiratory alkalosis.
D. Metabolic alkalosis results from excessive loss of acids or increased bicarbonate levels in the body. Hypoventilation leading to respiratory acidosis does not directly cause metabolic alkalosis.
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