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 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.

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 planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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