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
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.
B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.
C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.
D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.
Correct Answer is D
Explanation
A. Encourage oral intake of at least 3,000 mL of fluids per day:
This is not a priority intervention for ARDS. While maintaining adequate hydration is important, the primary focus in ARDS is on respiratory support and oxygenation. Excessive fluid intake may exacerbate pulmonary edema in these patients.
B. Offer high-protein and high-carbohydrate foods frequently:
Nutritional support is important in ARDS, but the primary concern is oxygenation and respiratory function. Offering high-protein and high-carbohydrate foods can support the client's overall nutritional needs, but it may not directly address the respiratory distress.
C. Administer low-flow oxygen continuously via nasal cannula:
This is not typically sufficient for ARDS. ARDS often requires higher levels of oxygen support, and low-flow oxygen may not meet the increased oxygen demand. More aggressive oxygenation strategies, such as non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation, may be necessary.
D. Place in a prone position:
Placing the patient in a prone position is a recommended intervention for ARDS. Prone positioning can improve oxygenation by optimizing ventilation-perfusion matching and reducing pressure on the lungs. This intervention is aimed at improving respiratory function in ARDS patients.
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