Emily, 25, shows signs of ptosis, dysphagia, and respiratory distress. The tensilon test is positive, and her ABG shows a PaO2 of 70 mmHg. What is the most immediate nursing intervention?
Initiate mechanical ventilation
Administer high-dose corticosteroids
Administer neostigmine
Provide supplemental oxygen
The Correct Answer is A
A. Emily is showing signs of myasthenic crisis, a life-threatening condition characterized by severe weakness of respiratory muscles. Initiating mechanical ventilation is the most immediate intervention to ensure adequate oxygenation and ventilation.
B. Administering high-dose corticosteroids may be part of the treatment for myasthenia gravis but would not address the immediate need for respiratory support.
C. Neostigmine is a medication used to treat myasthenia gravis but may not provide rapid relief in a crisis situation.
D. Providing supplemental oxygen may help temporarily but would not address the underlying respiratory muscle weakness and need for mechanical ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Avoid giving Paul a diet rich in fresh fruits, as they may contain harmful microorganisms that could cause infections. Instead, give him cooked or canned fruits that are safe to eat.
B. Strict adherence to Standard Precautions, which include hand hygiene, wearing gloves, gowns, and masks when necessary, is crucial to prevent infections in immunocompromised patients.
C. Do not place live plants in Paul's room, as they may harbor mold spores that could cause respiratory problems for Paul. Instead, use artificial plants or flowers that are easy to clean and disinfect.
D. Protective isolation measures, such as placing the patient in a private room and using appropriate barriers, can help minimize the risk of exposure to infectious agents.
E. Installing high-efficiency particulate air filters can help reduce airborne pathogens and allergens, which is important for patients with compromised immune systems.
Correct Answer is D
Explanation
A. Elevated C-reactive protein levels are not directly associated with an increased risk of hemorrhage.
B. C-reactive protein elevation is not indicative of an allergic response to medication.
C. C-reactive protein levels do not directly correlate with dehydration or fluid imbalance.
D. Elevated C-reactive protein levels are often seen in response to inflammation, including that caused by infection. In a post-operative patient, this elevation could indicate the early stages of an infection, and thus should be a priority concern for the nurse.
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