Medical Surgical Ventilator Settings & Mechanical Ventilation #2

Question

The nurse is caring for a client on a ventilator and is preparing to administer acetylcysteine (Mucomyst). Which action will the nurse perform following administration of acetylcysteine?

Answers

  1. Suctioning excess secretions.
    • Rationale:

      This answer is correct because after administration of acetylcysteine, the nurse should anticipate increased sputum that has been broken down and removable through suction. The medication helps break up thick mucus.

  2. Turn, cough, and deep breathe the client.
    • Rationale:

      This answer is not correct because the nurse will reposition the client frequently; however, the client is on a ventilator, so teaching to cough and deep breathe is not realistic for this client.

  3. Instruct the client that the medication may cause bradycardia.
    • Rationale:

      This answer is not correct because the medication does not cause bradycardia. This would not be included in the teaching plan.

  4. Remove any acetaminophen from the medication administration record.
    • Rationale:

      This answer is not correct because although acetylcysteine is an antidote for acetaminophen overdose, the question is not referring to over-dosage of acetaminophen.

Overview

The focus of this question is determining the most appropriate intervention to perform following administration of the medication acetylcysteine to a client on a ventilator. One important use of this medication is to thin respiratory secretions so that secretions may be easily suctioned to clear the client’s airway. So the appropriate action after administering this medication would be to suction excess secretions from the client’s airway.

Explanation

Learning Outcomes

Acetylcysteine is an antioxidant that has many therapeutic uses. When inhaled it is used to loosen and thin thick respiratory secretions which helps facilitate removal. For a client on a ventilator, the nurse must suction clients after acetylcysteine administration because these clients cannot protect their airways via coughing.

Test Taking Tip

A-B-C; excess secretions compromise a client’s airway so suctioning the client’s airway is the priority intervention.

Video Rationale