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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cherry jello is not a part of a full-liquid diet. While it is soft and easy to swallow, it does not provide the necessary nutrients that a patient recovering from surgery for laryngeal cancer would need.
Choice B rationale
Clear broth soup is part of a clear liquid diet, not a full liquid diet. A full liquid diet includes foods that are liquid at room temperature or melt at body temperature.
Choice C rationale
Chicken noodle soup is not suitable for a full-liquid diet. The noodles and chicken pieces could pose a swallowing risk for a patient recovering from surgery for laryngeal cancer.
Choice D rationale
Cream of potato soup is a suitable choice for a full-liquid diet. It is smooth and easy to swallow, and it provides necessary nutrients.
Correct Answer is C
Explanation
Choice A rationale
While it’s possible for a virus to reactivate in the body, this is not typically the case with the common cold. The common cold is a viral infection primarily in the nose, with most people recovering in seven to ten days.
Choice B rationale
While it’s true that cold season tends to end as the weather warms up, this doesn’t address the patient’s concern about their repeated colds. It’s important to note that colds are caused by viruses, which can be spread year-round, although they are more common in the colder months.
Choice C rationale
This is the correct answer. The common cold is indeed a virus that can be spread by a person two days before they experience any symptoms. This means that people can spread the virus before they know they’re sick, which can make it difficult to avoid catching a cold.
Choice D rationale
While wearing a mask can help prevent the spread of viruses, it’s not typically necessary for someone who is simply sensitive to colds. Masks are more commonly recommended for people who are already sick to prevent them from spreading the virus, or for people who are at high risk of serious complications from the cold.
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