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.

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Correct Answer is C

Explanation

A. Transformational leader:
Transformational leaders are characterized by their ability to inspire and motivate followers to achieve exceptional outcomes. They focus on building relationships, fostering creativity, and encouraging individual and team growth. Transformational leaders are often seen as visionary and charismatic.

B. Situational leader:
Situational leadership is a flexible approach where leaders adjust their style based on the situation and the readiness or maturity of their followers. The leader may use different leadership styles, ranging from directing to delegating, depending on the circumstances.

C. Bureaucratic leader:
Bureaucratic leaders strictly enforce rules and regulations. They rely on established policies and procedures to maintain order and control within the organization. This style is often associated with a more structured and rule-based approach to leadership.

D. Laissez-faire leader:
Laissez-faire leaders adopt a hands-off or delegative approach, providing little guidance or direction to their team members. They allow team members a high degree of autonomy and decision-making authority. While this style can promote creativity and independence, it may lead to a lack of structure and accountability in certain situations.

A. Close the fire doors on the unit B. Use a fire extinguisher to put out the fire C. Move any clients in the immediate vicinity. D. Activate the fire alarm

Correct Answer is C

Explanation

A. Close the fire doors on the unit:
Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.

B. Use a fire extinguisher to put out the fire:
While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.

C. Move any clients in the immediate vicinity:

Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire:

Rescue anyone in immediate danger.
Alarm: Activate the fire alarm.
Contain the fire by closing doors.
Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.

D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.

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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?

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