# Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the intensive care unit (ICU). On day 2, chest imaging shows new bilateral opacities, an echocardiogram shows normal left ventricular function, and the team diagnoses acute respiratory distress syndrome (ARDS). He is 170 cm tall and weighs 95 kg. On day 3 he remains severely hypoxemic, and a continuous infusion of cisatracurium, a neuromuscular blocker, is running. The protocol oxygen saturation target is 88–95%. The unit's train-of-four target during the infusion is 1–2 of 4 twitches. At 09:00 the nurse reviews these findings. Which finding requires the nurse's action FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630019  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the intensive care unit (ICU). On day 2, chest imaging shows new bilateral opacities, an echocardiogram shows normal left ventricular function, and the team diagnoses acute respiratory distress syndrome (ARDS). He is 170 cm tall and weighs 95 kg.

On day 3 he remains severely hypoxemic, and a continuous infusion of cisatracurium, a neuromuscular blocker, is running. The protocol oxygen saturation target is 88–95%. The unit's train-of-four target during the infusion is 1–2 of 4 twitches. At 09:00 the nurse reviews these findings. Which finding requires the nurse's action FIRST?

## 보기

1. Train-of-four shows 2 of 4 twitches at the ulnar nerve
2. Incomplete eyelid closure with mildly dry surfaces on both corneas
3. Oxygen saturation of 90% on the current ventilator settings
4. Sedative infusion paused at 08:30 for a daily awakening trial **✔ 정답**

**정답: 4**

## 해설

Neuromuscular blockers paralyze but provide no sedation or analgesia, so a client receiving one must stay deeply sedated. A sedative paused for a daily awakening trial while paralysis continues leaves him possibly awake and unable to move, which is the most urgent problem. Daily awakening trials are withheld while a neuromuscular blocker is running. Eye protection is needed but is less urgent, and the other findings are within target.

## 심화 해설

Priority action during neuromuscular blockade

A patient receiving a continuous neuromuscular blocker (NMB) infusion is chemically paralyzed but remains fully conscious unless adequate sedation and analgesia are provided. The most dangerous situation is one in which sedation is interrupted while paralysis continues, because the patient may be awake, aware of the ventilator, and unable to move or communicate. In this scenario, the sedative infusion was paused at 08:30 for a daily awakening trial while cisatracurium is still running. That combination creates a risk of awake paralysis and must be corrected before any other assessment finding is addressed.

Neuromuscular blockers paralyze but provide no sedation or analgesia, so a client receiving one must stay deeply sedated. Daily awakening trials, which involve interrupting or minimizing sedation to assess neurologic status and readiness for weaning, are withheld while an NMB is infusing. The rationale is not simply a protocol detail; it reflects the pharmacology of NMBs. Cisatracurium binds nicotinic acetylcholine receptors at the neuromuscular junction, preventing muscle contraction, but it does not cross the blood–brain barrier in clinically meaningful amounts and has no effect on consciousness. If the sedative is stopped, the patient may become fully alert while unable to move, blink, or breathe spontaneously. This is a medical emergency because it causes severe psychological distress, sympathetic surge, and loss of ventilator synchrony.

Watch out! A train-of-four result of 2 of 4 twitches is within the stated target of 1–2 of 4, so it does not require immediate action. The oxygen saturation of 90% is also within the protocol target of 88–95%. Incomplete eyelid closure with mildly dry corneas is a real concern during NMB infusion because paralysis prevents blinking and full lid closure, but it is a lower-acuity problem than awake paralysis. Eye lubrication and moisture-chamber protection should be initiated, but only after the sedation interruption is corrected.

The priority action is to resume the sedative infusion immediately and notify the team that a daily awakening trial was attempted during NMB therapy. Daily awakening trials are withheld while a neuromuscular blocker is running. Once the NMB is discontinued and neuromuscular function has recovered sufficiently, sedation interruption can be reconsidered. The clinical concern surrounding NMB use in the ICU has historically included prolonged weakness and other complications, but current evidence emphasizes that protocolized care, appropriate monitoring, and attention to sedation adequacy can reduce these risks. The key safety principle remains unchanged: paralysis without sedation is never acceptable.

| Finding | Target or expected finding | Priority |
| --- | --- | --- |
| Train-of-four 2/4 | Within target (1–2/4) | Monitor only |
| SpO2 90% | Within protocol range (88–95%) | Monitor only |
| Incomplete eyelid closure, dry corneas | Expected with NMB; requires eye care | Address after urgent issue |
| Sedative paused at 08:30 during NMB infusion | Contraindicated; risk of awake paralysis | Act first |

Key point! When a patient is receiving a continuous NMB, the nurse must verify that sedation and analgesia are running before performing any other assessment or intervention. A sedation hold during paralysis is the highest-priority safety violation in this scenario.

## 임상 시나리오

Sedation During Neuromuscular BlockadeNever interrupt sedation while a paralytic is running
Neuromuscular blockers paralyze muscles but provide no sedation or analgesia. The patient remains fully conscious and must stay deeply sedated throughout the infusion.

Daily awakening trials are withheld while an NMB is infusing. Interrupting sedation during paralysis creates awake paralysis, a medical emergency with severe distress and sympathetic surge.

Targets during NMB infusion: train-of-four 1–2/4 twitches and SpO2 88–95%. Both are acceptable and do not require immediate action.

CautionIf sedation is paused while paralysis continues, resume sedation immediately and assess for signs of awareness, pain, or ventilator dyssynchrony before addressing less urgent issues such as eye care.

## 핵심 개념

- **Neuromuscular blocker (NMB)** — Drug that paralyzes skeletal muscle but provides no sedation or analgesia; patient remains conscious unless adequately sedated.
- **Train-of-four (TOF)** — Peripheral nerve stimulation monitoring of neuromuscular blockade; target 1–2 of 4 twitches during continuous NMB infusion.
- **Daily awakening trial** — Planned interruption of sedation to assess neurologic status and weaning readiness; contraindicated during NMB infusion.
- **Awake paralysis** — Emergency state of consciousness with inability to move or communicate due to inadequate sedation during paralysis.
- **Cisatracurium** — Nondepolarizing NMB that binds nicotinic receptors at the neuromuscular junction without affecting consciousness.

## 같은 주제 문제

- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630016)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630017)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630018)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630020)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630021)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630022)
- [Situation: A 70-year-old woman with rheumatic heart disease is in the coronary care unit. …](https://mymerci.kr/pages/nclex_q.php?qn_id=630023)
- [Situation: A 70-year-old woman with rheumatic heart disease is in the coronary care unit. …](https://mymerci.kr/pages/nclex_q.php?qn_id=630024)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._