A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

Respond to ventilator alarms.

Report the absence of spontaneous respirations.

Encourage the client to take spontaneous breaths.

Place the call bell within reach.

Answer and Explanation

The Correct Answer is B

A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.

B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.

C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.

D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Pneumocystis pneumonia (PCP) is a common opportunistic infection in individuals with AIDS, particularly when their CD4 T-cell count falls below 200/mm3. PCP is caused by the fungus Pneumocystis jirovecii and is a significant cause of morbidity and mortality in AIDS patients. The CD4 T-cell count is a key indicator of immune function in HIV/AIDS patients. A CD4 T-cell count below 200/mm3 is indicative of severe immune suppression and significantly increases the risk of opportunistic infections such as pneumocystis pneumonia.

A. "My sense of smell is taking a long time to return." B. "Breathing through my stoma has diminished my sense of smell." C. "I can't smell what I eat, but hope to enjoy eating in the future." D. "I am happy to have a mild sense of taste despite no sense of smell."

Correct Answer is A

Explanation

A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.

B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.

C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.

D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.

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A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has AIDS. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at highest risk for developingdue to their

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client two months following a total laryngectomy. The nurse should recognize that which of the following statements made by the client indicates the need for further teaching?

Correct Answer is A

Explanation

A client with a history of hypertension and diagnosis of chronic renal disease asks a nurse how the disease occurred. The nurse should accurately respond to the client by making which statement?

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