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 ["A","C","D"]

Explanation

Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.

A. Written competency exams B. Insence training C. Simulation-based mock codes D. Peer-to-peer feedback sessions

Correct Answer is C

Explanation

Choice A rationale
Written competency exams can assess theoretical knowledge and understanding of procedures, but they may not accurately reflect practical skills or performance under real-life conditions.
Choice B rationale
Insence training, while potentially beneficial for enhancing certain skills, may not be the most effective method for improving confidence and performance in response to a “code”. It lacks the realism and immediacy of a code situation.
Choice C rationale
Simulation-based mock codes provide a safe environment where staff can practice their skills, learn from their mistakes, and improve their performance without risk to patients. They can enhance confidence, competence, and performance in real code situations.
Choice D rationale
Peer-to-peer feedback sessions can provide valuable insights and foster a culture of continuous learning and improvement. However, they may not offer the same level of structured, targeted skill development and performance improvement as simulation-based mock codes.

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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

A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?

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

Explanation

Several staff nurses express concern over their confidence levels and performance to the nurse in charge of performance improvement after responding to a "code.”. The best way for the nurse in charge to evaluate and improve performance is to implement which of the following?

Correct Answer is C

Explanation

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