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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Related Questions
Correct Answer is D
Explanation
Methotrexate is a medication that interferes with cell division and can cause birth defects or miscarriage if taken during pregnancy. The medication can also pass into breast milk and harm the baby. Therefore, the nurse should advisethe client to stop taking methotrexate at least 3 months before trying to conceive and to use effective contraception while on the medication.
Correct Answer is C
Explanation
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.

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