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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Use many "I's" in the message: Overusing the word "I" can make a message seem self-centered and less engaging. Instead, a balanced approach that highlights accomplishments and skills without excessive focus on oneself is more effective. Using "I" sparingly helps maintain professionalism and keeps the focus on how the nurse's qualifications meet the needs of potential employers.
B. Be sure to remove your address and phone number and replace it with your email because your resume will be on the internet: While protecting personal information is important, completely removing contact details is not advisable. Including a professional email along with appropriate contact information allows potential employers to reach out directly. Instead of removing all personal contact information, consider using a professional email address while maintaining other essential contact details as needed.
C. Save your resume in .docx format: While .docx is a commonly used format, it is not the best choice for online job applications, as some applicant tracking systems may not parse it correctly. Instead, saving the resume as a PDF is often recommended, as it preserves formatting and is widely accepted by employers. Therefore, this option may not be the most effective recommendation.
D. Focus on selling yourself: This is a good recommendation for a nurse searching for a job. Effectively presenting skills, experiences, and accomplishments demonstrates to potential employers how the nurse can add value to their organization. A well-crafted resume and cover letter should highlight the nurse's qualifications, passion for nursing, and ability to meet the specific needs of the position and the organization. This approach can significantly enhance the chances of securing an interview and ultimately a job.
Correct Answer is A
Explanation
A. Incentive spirometry: This is the most effective independent nursing measure to prevent atelectasis. Incentive spirometry encourages deep breathing and lung expansion, which helps to keep the alveoli open and reduces the risk of collapse. It is particularly beneficial for clients at risk for atelectasis, such as those who have had surgery, are immobile, or have respiratory issues. Regular use of the incentive spirometer promotes optimal lung function and helps prevent the development of atelectasis.
B. Increase oral fluid intake: While maintaining adequate hydration is important for overall health and can help thin secretions, it is not as directly effective in preventing atelectasis as incentive spirometry. Increased fluid intake alone does not promote deep breathing or lung expansion, which are critical in preventing airway collapse.
C. Ambulation: Although ambulation is an important intervention for promoting overall mobility and respiratory function, it may not be as practical for all clients, especially those who are unable to move independently. While getting the client up and moving can help prevent atelectasis, the most immediate and effective measure remains the use of incentive spirometry, which can be performed regardless of the client’s mobility status.
D. Oxygen therapy: While oxygen therapy can help improve oxygenation in clients with respiratory issues, it does not directly prevent atelectasis. Providing supplemental oxygen does not address the need for lung expansion and deep breathing, which are essential in maintaining alveolar patency. Therefore, oxygen therapy should not be prioritized as the primary independent measure to prevent atelectasis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
