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 D

Explanation

A. Develop a quality improvement program for nurses involved in medication administration errors. While quality improvement programs are essential, implementing a targeted program without first analyzing the root causes of errors may not effectively address the underlying issues. A broader review of system-wide factors contributing to medication errors is necessary before designing an intervention.
B. Require staff nurses to demonstrate competency by passing a medication administration examination. Competency assessments may help identify knowledge gaps, but they do not address system-based errors such as workload issues, unclear protocols, or distractions during medication administration. A root cause analysis should be conducted first to ensure that interventions target the actual sources of errors.
C. Provide an inservice on medication administration to all the nurses. Educational sessions can reinforce safe practices, but without identifying the specific factors contributing to errors, they may not be effective. Training should be tailored to address the findings from an initial review of the medication errors.
D. Review the events leading up to each medication administration error. The first step in continuous quality improvement is conducting a thorough analysis of the errors, identifying patterns, and determining root causes. This helps in designing targeted interventions, whether they involve process changes, additional training, or improved safety protocols.

A. Vanilla ice cream B. Chicken noodle soup C. Hot herbal tea D. Fruit-flavored popsicles

Correct Answer is D

Explanation

A. Vanilla ice cream: While ice cream may be soothing for a sore throat, it is not the most nutritious option for a client with bacterial pharyngitis. Although it provides calories and can help with throat discomfort, it lacks essential nutrients that support recovery and may not help with hydration, which is critical during illness.
B. Chicken noodle soup: This option can be beneficial due to its warm temperature and potential nutritional value, including protein and hydration. However, the heat of the soup may irritate a sore throat further, especially if it is too hot. It can be a good option, but care should be taken to ensure it is at a comfortable temperature for the client.
C. Hot herbal tea: While herbal tea can provide hydration and soothing effects, it may also irritate a sore throat if served too hot. The temperature of the tea is a consideration, as consuming very hot liquids can exacerbate throat discomfort. Therefore, while it can be helpful, it may not be the best option for promoting comfort.
D. Fruit-flavored popsicles: This is the most recommended option for promoting nutrition during treatment for bacterial pharyngitis. Popsicles are cold, which can soothe a sore throat and reduce inflammation. They are also hydrating, easy to swallow, and can provide some calories, making them a good choice for maintaining nutrition and comfort during recovery. This option balances soothing relief with hydration and nutrition effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Correct Answer is D

Explanation

A client is being treated for bacterial pharyngitis. Which of the following should a nurse recommend when promoting the client's nutrition during treatment?

Correct Answer is D

Explanation

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