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. Iritis B. Wrinkles in the skin C. Facial rash D. Constipation

Correct Answer is C

Explanation

This is because SLE is an autoimmune disorder that causes inflammation and damage to various tissues and organs, including the skin. A facial rash, also known as a malar rash or butterfly rash, is one of the characteristic signs of SLE and affects about half of people with the condition.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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