A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

Rationale:

A. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed alters body mechanics and may complicate the transfer by increasing the angle of elevation, which can lead to strain or improper alignment during the move.

B. Use a pillow underneath the client's head when repositioning a client in bed: A pillow can aid in comfort but does not contribute to safe body mechanics during repositioning. It may also interfere with alignment or reduce the ability to properly lift or turn the client.

C. Transfer on the client's weaker side when moving a client from a bed to a chair: Transferring toward the weaker side increases the risk of instability and falls. Safe ergonomic practice involves moving clients toward their stronger side to encourage participation and minimize staff effort.

D. Use a lateral transfer device when moving a client from a bed to a stretcher: Lateral transfer devices reduce friction between surfaces, making it easier to move the client without excessive force. This protects both the client and the nurse from musculoskeletal injuries and supports safe practice.

Rationale:

A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.

B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.

C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.

D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.