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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Related Questions
Correct Answer is A
Explanation
A. Place the client in a private room with a special ventilation system.
The primary method to prevent the transmission of tuberculosis is to place the client in a negative pressure room with adequate ventilation. This helps to reduce the risk of airborne transmission of the Mycobacterium tuberculosis bacteria.
B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:
Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.
C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.
D. Assign the client to a room with other clients who require droplet precautions:
Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.
Correct Answer is B
Explanation
A. “Check your oxygen equipment once each week.”
Checking the oxygen equipment once a week is insufficient. The equipment should be regularly inspected for safety, including tubing, connections, and the condition of the oxygen concentrator or tank.
B. “Do not adjust the oxygen flow rate.”
The nurse should include in the teaching that the client should not adjust the oxygen flow rate without consulting their healthcare provider. Adjusting the oxygen flow rate without proper guidance can lead to inappropriate oxygen delivery, which may be harmful.
C. “Store unused oxygen tanks horizontally.”
Oxygen tanks should be stored in an upright position to prevent damage to the tank valve. Storing them horizontally can increase the risk of leaks or damage.
D. “Keep wool blankets on your bed.”
Wool blankets and other items that generate static electricity should be avoided near oxygen equipment, as they can increase the risk of fire. The client should be advised to use non-static bedding and clothing.
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