As the nurse caring for a ventilator-dependent client who is receiving vecuronium bromide, you assess the level of neuromuscular blockade using "Train-of Four" (TOF) peripheral nerve stimulation. When would you know you have the correct amount of the paralytic being delivered?
The client displays zero twitch responses.
The client displays three out of four twitch responses.
The client can blink their eyes on command.
The client displays one to two out of four twitch responses.
The Correct Answer is D
A. The client displays zero twitch responses: Zero twitches indicate complete neuromuscular blockade, which is usually excessive and can lead to complications such as prolonged paralysis or respiratory compromise. This level is not desired for most ventilated patients receiving titrated paralytics.
B. The client displays three out of four twitch responses: Three twitches suggest a light blockade. This may not provide sufficient muscle relaxation for optimal ventilator synchrony or procedural requirements and may require an increase in paralytic dose.
C. The client can blink their eyes on command: The ability to follow commands indicates minimal or no neuromuscular blockade, which is inadequate for clients requiring paralysis for mechanical ventilation or other critical interventions.
D. The client displays one to two out of four twitch responses: One to two twitches on TOF stimulation represent the recommended level of partial neuromuscular blockade. This ensures adequate paralysis for mechanical ventilation while minimizing the risk of overdose and allowing some assessment of neuromuscular function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypoxia due to tension pneumothorax: Tension pneumothorax can cause severe hypoxia, hypotension, and absent breath sounds on the affected side. However, this client has bilateral crackles and wheezes, which are not consistent with a unilateral pneumothorax. The presentation suggests widespread alveolar involvement rather than localized lung collapse.
B. Hyperventilation due to anxiety: Hyperventilation from anxiety would typically cause respiratory alkalosis, characterized by low PaCO₂. This client has elevated PaCO₂ (50 mmHg) and low pH (7.32), indicating respiratory acidosis, which is inconsistent with hyperventilation.
C. Excessive use of sedation: Sedation can depress respiratory drive and contribute to hypoventilation. While this can worsen respiratory status, the presence of crackles, wheezes, and severe hypoxemia suggests underlying airway obstruction and alveolar filling rather than purely medication-induced respiratory depression.
D. Alveolar hypoventilation due to airway obstruction: The client’s blood gas shows hypoxemia (PaO₂ 50 mmHg, SaO₂ 70%) and hypercapnia (PaCO₂ 50 mmHg) with acidemia (pH 7.32), which indicates alveolar hypoventilation. Crackles and wheezes suggest obstruction and fluid accumulation in the alveoli, consistent with acute respiratory distress syndrome pathology.
Correct Answer is B
Explanation
A. Administer osmotic diuretics as prescribed and open drain to remove cerebrospinal fluid: Osmotic diuretics and CSF drainage are used to lower elevated intracranial pressure. In this scenario, the ICP is 15 mmHg, which is within normal limits, so lowering ICP is not the immediate priority.
B. Participate in interventions to increase cerebral perfusion pressure: Cerebral perfusion pressure (CPP) is calculated as MAP minus ICP. With a MAP of 70 mmHg and ICP of 15 mmHg, CPP is 55 mmHg, which is at the lower threshold of adequate cerebral perfusion. Supporting CPP through interventions is critical to maintain brain oxygenation and prevent further injury.
C. Prepare the client for having burr holes drilled into the skull: Surgical intervention is reserved for cases of refractory intracranial hypertension or localized mass effect. This is not immediately indicated given the current ICP and MAP values.
D. Position the client in the high Fowler position as tolerated: While positioning can influence ICP, high Fowler may actually reduce cerebral perfusion by lowering MAP relative to ICP. Maintaining neutral alignment and interventions to optimize CPP are higher priorities in brain stem herniation.
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