Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

The patient has no cough reflex when suctioned.

The patient's oxygen saturation is 90% to 93%

The patient does not respond to voice.

No sedative is ordered for the patient

Answer and Explanation

The Correct Answer is D

D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.

A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.

B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.

C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.

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Correct Answer is B

Explanation

B. This is a reasonable action given the client's respiratory rate and potential hypoxemia resulting from the sucking chest wound. Providing supplemental oxygen can help improve oxygenation and support the client's respiratory effort. However, it doesn't directly address the underlying cause of the shock.

A. In this scenario, the client's vital signs indicate signs of shock, which could be due to significant blood loss from the sucking chest wound. While inserting a central line may be necessary for administering fluids and medications rapidly, it's not the immediate priority in this situation. Stabilizing the client's condition takes precedence.

C. Elevating the foot of the bed to a 90° angle is not appropriate in this situation. This position can further decrease venous return to the heart, potentially exacerbating the client's hypotension and shock. It's crucial to maintain a neutral or slightly elevated position to optimize venous return.

D. While it's important to assess the wound and monitor for any changes, removing the dressing on a sucking chest wound without appropriate precautions can worsen the client's condition. The dressing helps to maintain a seal over the wound, preventing further air from entering the pleural space and worsening the tension pneumothorax. Removing the dressing should be done cautiously and preferably by a healthcare provider trained in managing chest trauma.

A. Respiratory rate B. Stroke volume C. Heart rate D. Blood pressure

Correct Answer is ["B","C"]

Explanation

B. stroke volume is the amount of blood ejected from the left ventricle with each contraction (systole) of the heart. Changes in stroke volume directly affect cardiac output. An increase in stroke volume leads to an increase in cardiac output, while a decrease in stroke volume results in a decrease in cardiac output. Factors that can affect stroke volume include preload, afterload, and contractility of the heart.

C. Heart rate refers to the number of heartbeats per minute. Heart rate directly affects cardiac output by determining how frequently the heart contracts and pumps blood. An increase in heart rate (tachycardia) leads to an increase in cardiac output, while a decrease in heart rate (bradycardia) results in a decrease in cardiac output. Factors such as sympathetic and parasympathetic nervous system activity, hormones, and medications can influence heart rate.

A. Respiratory rate does not directly affect stroke volume or heart rate but changes in respiratory rate can indirectly impact cardiac output through their effects on venous return and preload.

D. Blood pressure represents the force exerted by the blood against the walls of the arteries. While blood pressure does not directly affect cardiac output, it is influenced by cardiac output and systemic vascular resistance (SVR).

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Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Which of the following factors can directly affect cardiac output?

Correct Answer is ["B","C"]

Explanation

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