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,C,D
These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.
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