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

Basal cell carcinoma is the most common type of skin cancer and usually occurs on sun-exposed areas of the skin. It is slow-growing and rarely metastasizes. It appears as a small, translucent papule with rolled borders that may ulcerate and bleed.

A. Dietary modifications occur during pregnancy when taking this medication. B. The client can breast feed when taking this medication. C. Dosage of the medication will be reduced during pregnancy. D. The medication should be discontinued 3 months prior to a planned pregnancy.

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.

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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 assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?

Correct Answer is B

Explanation

A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client?

Correct Answer is D

Explanation

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