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 C

Explanation

Acyclovir is an antiviral medication that can reduce the severity and duration of herpes zoster symptoms, such as pain, itching, and blisters. Acyclovir can also prevent complications, such as postherpetic neuralgia, which is a chronic nerve pain that can occur after herpes zoster infection.

A. "This procedure involves placing the client into a shower and removing the dead tissue." B. "Dead tissue will be non-surgically removed." C. "Large incisions will be made in the eschar to improve circulation." D. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area."

Correct Answer is C

Explanation

An escharotomy is a surgical procedure that involves making incisions in the eschar, which is the hard, blackened tissue that forms over a severe burn wound. The eschar can restrict blood flow and cause compartment syndrome, which can lead to tissue necrosis and nerve damage. By cutting through the eschar, the pressure is relieved and circulation is restored. This procedure does not involve removing the dead tissue, which is done by debridement or hydrotherapy. A skin graft is a different procedure that involves transplanting healthy skin from another site to cover a burn wound.

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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 has herpes zoster. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is C

Explanation

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A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?

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