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 D

Explanation

D. A pulmonary artery catheter is used to monitor hemodynamic status. It provides valuable information about cardiac function, preload, afterload, and cardiac output. By measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, and central venous pressure, a pulmonary artery catheter helps assess the effectiveness of cardiac function and guide management in critically ill patients, especially those with conditions such as heart failure, shock, or pulmonary hypertension.

A. A pulmonary artery catheter, also known as a Swan-Ganz catheter, is not used to monitor intracranial pressure. Instead, it is primarily used to assess hemodynamic status and cardiac function by measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, central venous pressure, and cardiac output.

B. A pulmonary artery catheter is not used to directly monitor renal function. While changes in hemodynamic status can impact renal perfusion and function, the primary purpose of a pulmonary artery catheter is to assess cardiac function and hemodynamics, rather than renal function.

C. A pulmonary artery catheter is not used to monitor spinal cord perfusion. Although alterations in hemodynamic status can affect spinal cord perfusion indirectly, the main purpose of a pulmonary artery catheter is to evaluate cardiac function and hemodynamics.

A. Acetaminophen (Tylenol) 650 mg rectally. B. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. C. Administer normal saline IV at 500 mL/hr. D. Start norepinephrine to keep blood pressure above 90 mm Hg.

Correct Answer is C

Explanation

C. The first intervention should be to administer normal saline IV at 500 mL/hr to address the immediate concern of hypotension and inadequate tissue perfusion.

A. While fever control is important, especially in septic shock, administering acetaminophen should not be the first intervention in a patient with severe hypotension and shock. Addressing the low blood pressure and perfusion is a higher priority.

B. Hyperglycemia is common in critically ill patients, including those with septic shock. However, in this scenario, the patient's severely low blood pressure and signs of shock take precedence over managing hyperglycemia. Insulin therapy can be initiated later once the patient's hemodynamic status is stabilized.

D. Norepinephrine is a vasopressor medication commonly used in septic shock to increase blood pressure and improve perfusion to vital organs. It helps counteract the vasodilation and hypotension characteristic of septic shock.

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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 is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Correct Answer is D

Explanation

A patient with septic shock has a BP of 70/46 mm Hg. pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104" F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Correct Answer is C

Explanation

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