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

Report the absence of spontaneous respirations.

Encourage the patient to attempt to breathe on their own.

Provide passive range-of-motion exercises.

Respond to ventilator alarms.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.

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Correct Answer is B

Explanation

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

A. Thoracentesis. B. Obtain ABGs. C. Computed tomography (CT) of the chest. D. Prepare for insertion of a chest tube. E. Obtain intravenous access. F. Pulmonary Function Tests (PFTS). .

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

Explanation

Choice A rationale
Thoracentesis may be performed to remove air from the pleural space in a client with a pneumothorax.
Choice B rationale
Obtaining arterial blood gases (ABGs) can help assess the client’s respiratory status and the severity of the pneumothorax.
Choice C rationale
A computed tomography (CT) scan of the chest can provide detailed images of the lungs and can help confirm the diagnosis of a pneumothorax.
Choice D rationale
Preparation for the insertion of a chest tube may be necessary to remove air from the pleural space and allow the lung to re-expand in a client with a pneumothorax.
Choice E rationale
Obtaining intravenous access is often necessary for administering medications and fluids.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

Explanation

A nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record. What prescriptions should the nurse anticipate for a client who has a pneumothorax?

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

Explanation

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