A patient with acute respiratory distress syndrome is receiving a paralyzing agent. With a Train-of-four (TOF) assessment, the patient’s thumb twitches 3 times. How would the nurse interpret this response?

The patient’s paralysing agent dose in adequate, but needs to be given more often

The patients paralyzing agent dose is too low and needs to be increased

The patient’s paralyzing agent dose in appropriate and does not need to be changed

The patients paralyzing agent dose is too high and needs to be reduced

Answer and Explanation

The Correct Answer is A

A. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.

B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.

C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.

D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The patient may need suctioning:
A high-pressure alarm indicates increased resistance to airflow, which could be caused by secretions or mucus in the airways. Suctioning is the appropriate intervention to clear the airways of excess secretions, reducing airway resistance and preventing the high-pressure alarm.

B. The patient extubated himself:
If the patient extubates himself (removes the endotracheal tube), this may result in a low-pressure alarm, not a high-pressure alarm. The low-pressure alarm is triggered when there is a loss of pressure within the ventilator circuit due to disconnection or extubation.

C. The ventilator tubing may be disconnected:
If the ventilator tubing is disconnected, it is more likely to trigger a low-pressure alarm, indicating a loss of pressure in the ventilator circuit. This is not the primary cause of increased resistance seen with a high-pressure alarm.

D. The cuff at the end of the endotracheal tube is deflated:
A deflated cuff can lead to air leakage around the endotracheal tube but is not the primary cause of increased airway resistance seen with a high-pressure alarm. It may cause a low-pressure alarm if cuff pressure is monitored.

A. Increased anteroposterior diameter of the chest B. Petechiae on chest C. Oxygen saturation level 96% D. Respiratory alkalosis

Correct Answer is A

Explanation

A. Increased anteroposterior diameter of the chest
In emphysema, there is often hyperinflation of the lungs and destruction of the alveolar walls, leading to loss of lung elasticity. This results in increased air trapping and a characteristic "barrel chest" appearance, with an increased anteroposterior diameter.

B. Petechiae on chest:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not commonly associated with COPD and emphysema.

C. Oxygen saturation level 96%:
Oxygen saturation level of 96% is within the normal range. While oxygen saturation can be affected in COPD, the value provided is not indicative of severe hypoxemia.

D. Respiratory alkalosis:
Respiratory alkalosis is not typically associated with COPD and emphysema. In fact, respiratory acidosis is more commonly seen in these conditions due to impaired gas exchange and retention of carbon dioxide.

View Question and Answer

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

A patient with acute respiratory distress syndrome is receiving a paralyzing agent. With a Train-of-four (TOF) assessment, the patient’s thumb twitches 3 times. How would the nurse interpret this response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings?

Correct Answer is A

Explanation

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of the nurses clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance?

The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO: 68 mm Hg Base excess-2 Pa0: 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?