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. Right-sided heart failure leads to congestion of the systemic venous circulation, resulting in increased central venous pressure (CVP). Elevated CVP is a hallmark sign of right-sided heart failure and is often used clinically to assess right ventricular preload and volume status.

A. BNP is a hormone secreted by the heart in response to increased ventricular stretch and volume overload, and its levels are usually elevated in heart failure, including both left-sided and right-sided heart failure.

C. Specific gravity refers to the concentration of solutes in urine and is often used as a measure of urine concentration.

D. Pulmonary artery wedge pressure (PAWP) is a measure of left atrial pressure and left ventricular end- diastolic pressure. In right-sided heart failure, the primary hemodynamic abnormality is congestion of the systemic venous circulation, rather than elevated left-sided pressures.

A. indicates turbulent blood flow through a valve. B. is an extra sound due to blood entering an inflexible chamber. C. is a high-pitched sound due to a narrow valve. D. means that there is some inflammation around the heart.

Correct Answer is A

Explanation

A. A heart murmur typically indicates turbulent blood flow through a heart valve. This turbulence can occur due to various reasons, such as valve stenosis (narrowing), regurgitation (leakage), or structural abnormalities of the valves. The turbulent flow produces audible sounds that can be heard with a stethoscope during cardiac auscultation.

B. A heart murmur is not caused by blood entering an inflexible chamber. Instead, it is caused by turbulent blood flow through the heart valves. The sound produced by this turbulent flow may vary depending on the underlying pathology of the valve.

C. While heart murmurs can be described based on their characteristics (such as high-pitched or low- pitched), the presence of a heart murmur does not necessarily indicate a narrow valve. Murmurs can occur due to various valve abnormalities, including stenosis (narrowing) or regurgitation (leakage). The pitch and quality of the murmur may vary depending on the underlying pathology and the location of the abnormality.

D. A heart murmur is not typically associated with inflammation around the heart. While inflammation of the heart (such as myocarditis or pericarditis) can cause symptoms and abnormal sounds, these conditions would not be described specifically as a "heart murmur."

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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