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

The correct answer is choiceC. “I will follow a daily diet high in calories and protein.”

Choice A rationale:

Inhaling slowly through pursed lips is incorrect.The correct technique is toexhaleslowly through pursed lips, which helps to keep the airways open longer, allowing for better air exchange and reducing shortness of breath.

Choice B rationale:

Lying on the stomach to practice abdominal breathing is not a recommended strategy for managing emphysema.Abdominal or diaphragmatic breathing can be beneficial, but it is typically practiced in a comfortable, upright position.

Choice C rationale:

Clients with emphysema often have an increased caloric demand due to the effort required to breathe. A diet high in calories and protein can help maintain energy levels and prevent muscle wasting.

Choice D rationale:

Avoiding a flu shot is incorrect.Patients with emphysema are at higher risk for respiratory infections, and getting an annual flu shot is crucial to prevent complications.

A. Instruct the client to use pursed-lip breathing. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Restrict the client's fluid intake to less than 2 L/day.

Correct Answer is A

Explanation

This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.

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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 teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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