A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Administer pantoprazole as prescribed.

Reposition the endotracheal tube to the opposite side of the mouth daily.

Verify the prescribed ventilator settings daily.

Elevate the head of the bed to at least 30°.

Apply restraints if the client becomes agitated.

Answer and Explanation

Correct Answer : A,B,D

Correct answers: A, B ,D

A. Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.

B. Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.

D. Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.

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Correct Answer is B

Explanation

This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.

A. Activities that could result in bleeding B. Oral fluid intake to between meals only C. All visitors from entering the client's room D. Fresh flowers and potted plants in the room

Correct Answer is D

Explanation

The correct answer is choiceD. Fresh flowers and potted plants in the room.

Choice A rationale:

While activities that could result in bleeding should be avoided in patients with low platelet counts, this is not directly related to neutropenia.Neutropenia primarily increases the risk of infection rather than bleeding.

Choice B rationale:

Restricting oral fluid intake to between meals is not relevant to managing neutropenia.Adequate hydration is important, but the timing of fluid intake does not impact neutropenia management.

Choice C rationale:

While limiting visitors can help reduce the risk of infection, it is not necessary to restrict all visitors.Instead, visitors should follow strict hygiene practices, such as handwashing and wearing masks, to minimize infection risk.

Choice D rationale:

Fresh flowers and potted plants can harbor bacteria and fungi, which pose a significant infection risk to neutropenic patients.Therefore, these should be avoided in the patient’s room.

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A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?

Correct Answer is B

Explanation

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