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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because basal cell carcinoma originates from the basal layer of the epidermis, which does not have access to blood vessels or lymphatics that can facilitate spreading to other organs. Basal cell carcinoma usually grows slowly and locally, and can be treated with surgery or radiation.
Correct Answer is B
Explanation
This is because older adults may not have typical signs and symptoms of pneumonia, such as fever, cough, and chest pain. Instead, they may present with confusion, lethargy, or delirium due to hypoxia or dehydration.
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