A nurse is caring for a client receiving mechanical ventilation. The nurse should prioritize which action associated with neuromuscular blockade use?

Respond to ventilator alarms.

Report the absence of spontaneous respirations.

Provide passive range-of-motion exercises.

Encourage the client to attempt to breathe on their own.

Answer and Explanation

The Correct Answer is C

A. Respond to ventilator alarms: While it is crucial to respond to ventilator alarms promptly to ensure the client’s safety and adequate ventilation, this action is not the highest priority in relation to the use of neuromuscular blockers. The use of neuromuscular blockade requires a broader focus on the patient's overall care and safety.
B. Report the absence of spontaneous respirations: Reporting the absence of spontaneous respirations is important, as neuromuscular blockers can cause paralysis of the respiratory muscles. However, the focus should be on maintaining the client's safety and comfort while they are on mechanical ventilation, rather than just reporting findings.
C. Provide passive range-of-motion exercises: This is the priority action when caring for a client receiving neuromuscular blockers. Since the client cannot move voluntarily due to the effects of the neuromuscular blockade, passive range-of-motion exercises are essential to prevent complications such as contractures and muscle atrophy. This intervention helps maintain joint mobility and circulation, which is critical in patients who are mechanically ventilated for an extended period.
D. Encourage the client to attempt to breathe on their own: Encouraging the client to breathe on their own is not appropriate when they are receiving neuromuscular blockade, as their respiratory muscles are paralyzed. Instead, the focus should be on ensuring that the mechanical ventilation settings are adequate to provide proper oxygenation and ventilation while the client cannot initiate breaths independently. This action could lead to respiratory distress if attempted while under neuromuscular blockade.

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Correct Answer is A

Explanation

A. The importance of adhering closely to the prescribed medication regimen. Tuberculosis requires strict adherence to a long-term antibiotic regimen, typically lasting 6 to 9 months, to prevent drug resistance, treatment failure, and disease relapse. Noncompliance can lead to multidrug-resistant TB (MDR-TB), which is more difficult to treat. Directly observed therapy (DOT) is often recommended to ensure adherence.
B. The client must remain in respiratory isolation until medication treatment ends. While respiratory isolation is essential for active TB, it is not required until the full course of treatment is completed. Isolation is typically maintained until the client has received at least two weeks of effective therapy, symptoms improve, and three consecutive sputum smears are negative for acid-fast bacilli (AFB).
C. The fact that the disease is self-limiting, but can take up to two years to resolve. TB is not self-limiting; without proper treatment, it can persist indefinitely, worsen, and become fatal. Standard treatment with first-line drugs such as isoniazid, rifampin, ethambutol, and pyrazinamide effectively eradicates the infection within 6 to 9 months in most cases.
D. The importance of participating in physical therapy to re-establish functional abilities. While TB can cause fatigue and weakness, physical therapy is not a primary focus of treatment. The priority is to eradicate the infection through strict medication adherence, as untreated TB can progress to severe pulmonary damage, systemic involvement, and complications.

A. Self-administer prescribed antibiotics on time and don't skip doses B. Contact HCP promptly for drooling or inability to fully open mouth C. Drink at least 2-3 liters of fluid/day unless contraindicated D. Do not share beverage cups or food utensils with other individuals E. Inspect body for skin rash development twice per day.

Correct Answer is ["B","C","D"]

Explanation

A. Self-administer prescribed antibiotics on time and don't skip doses: This statement is not applicable for viral pharyngitis, as antibiotics are ineffective against viral infections. Teaching should clarify that antibiotics are only prescribed for bacterial infections. Therefore, this information should not be included in the teaching plan for viral pharyngitis.
B. Contact HCP promptly for drooling or inability to fully open mouth: This is an important teaching point, as these symptoms may indicate a severe throat infection or complications that require immediate medical attention. Prompt contact with the healthcare provider is essential for any signs of difficulty in swallowing or mouth opening, which may suggest a need for further evaluation and treatment.
C. Drink at least 2-3 liters of fluid/day unless contraindicated: Encouraging adequate hydration is critical for clients with viral pharyngitis, as it helps soothe the throat, thin mucus, and prevent dehydration. This recommendation is appropriate and should be included in the teaching plan, ensuring students understand the importance of hydration in managing symptoms.
D. Do not share beverage cups or food utensils with other individuals: This is a vital precaution to prevent the spread of the viral infection to others. Educating clients on the importance of hygiene and avoiding sharing personal items can help limit transmission and protect others from becoming infected.
E. Inspect body for skin rash development twice per day: While it is important to monitor for any unusual symptoms, this specific action may not be necessary for viral pharyngitis unless there are other clinical indicators that suggest a possible rash. Viral pharyngitis typically does not warrant routine skin inspections for rash development, making this point less relevant in the context of the teaching plan.

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A nurse is caring for a client receiving mechanical ventilation. The nurse should prioritize which action associated with neuromuscular blockade use?

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