A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneously every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A Reason: This choice is correct because allowing the drainage to drip onto a sterile gauze pad may help to identify if it is cerebrospinal fluid (CSF), which is a clear fluid that surrounds and protects the brain and spinal cord. CSF leakage from the nose (rhinorrhea) may indicate a basilar skull fracture, which is a serious injury that can cause intracranial bleeding, infection, or brain damage. The nurse should test the drainage for the presence of glucose or the halo sign, which are indicators of CSF.

Choice B Reason: This choice is incorrect because obtaining a culture of the specimen using sterile swabs may introduce bacteria into the nasal cavity and increase the risk of infection. The nurse should avoid inserting anything into the nose or mouth of a client who has a suspected basilar skull fracture.

Choice C Reason: This choice is incorrect because inserting sterile packing into the nares may increase the pressure in the cranial cavity and worsen the injury. The nurse should avoid applying pressure or occluding the nose or ears of a client who has a suspected basilar skull fracture.

Choice D Reason: This choice is incorrect because suctioning the nose gently with a bulb syringe may damage the nasal mucosa and cause bleeding. The nurse should avoid suctioning or irrigating the nose or ears of a client who has a suspected basilar skull fracture.

Choice A Reason: This choice is correct because verifying the prescribed ventilator settings daily is an important intervention to ensure that the client is receiving adequate ventilation and oxygenation. The ventilator settings include parameters such as tidal volume, respiratory rate, fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (PIP). The nurse should check that the settings match the prescription and report any changes or alarms to the provider.

Choice B Reason: This choice is incorrect because applying restraints if the client becomes agitated is not a recommended intervention to prevent complications. Restraints may cause injury, infection, or psychological distress to the client and increase the risk of ventilator-associated pneumonia (VAP). The nurse should use alternative methods to manage agitation, such as sedation, analgesia, or environmental modification.

Choice C Reason: This choice is correct because administering pantoprazole as prescribed is an important intervention to prevent complications. Pantoprazole is a proton pump inhibitor (PPI) that reduces the production of stomach acid and prevents gastroesophageal reflux disease (GERD) and stress ulcers. These conditions can cause aspiration, bleeding, or infection in clients who are receiving mechanical ventilation.

Choice D Reason: This choice is incorrect because repositioning the endotracheal tube to the opposite side of the mouth daily is not a recommended intervention to prevent complications. Repositioning the endotracheal tube may cause trauma, bleeding, or displacement of the tube, which can compromise the airway and ventilation of the client. The nurse should secure the tube with tape or a device and check its position regularly using chest x-ray or end-tidal CO2 monitoring.

Choice E Reason: This choice is correct because elevating the head of the bed to at least 30° is an important intervention to prevent complications. Elevatin the head of the bed helps to reduce the risk of aspiration, which is the inhalation of gastric contents or secretions into the lungs. Aspiration can cause pneumonia, atelectasis, or respiratory failure in clients who are receiving mechanical ventilation.