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)
Apply restraints if the client becomes agitated.
Administer pantoprazole as prescribed.
Verify the prescribed ventilator settings daily.
Elevate the head of the bed to at least 30 degrees.
Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer : B,C,D,E
Choice A reason: Applying restraints if the client becomes agitated should be done with caution and only as a last resort. Restraints can increase the risk of injury and should be used according to hospital policy and only when absolutely necessary. Alternative methods to calm the client should be explored first.
Choice B reason: Administering pantoprazole as prescribed is important to prevent stress ulcers and gastrointestinal bleeding, which are common complications in clients receiving mechanical ventilation. Pantoprazole is a proton pump inhibitor that reduces stomach acid production.
Choice C reason: Verifying the prescribed ventilator settings daily is crucial to ensure the client is receiving the correct ventilation support. Regular checks help identify any discrepancies or changes in the client’s condition that may require adjustments to the ventilator settings.
Choice D reason: Elevating the head of the bed to at least 30 degrees helps prevent ventilator-associated pneumonia (VAP) by reducing the risk of aspiration. This position also aids in lung expansion and improves oxygenation.
Choice E reason: Repositioning the endotracheal tube to the opposite side of the mouth daily helps prevent pressure ulcers and sores in the mouth. Regular repositioning reduces the risk of tissue damage and infection.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
The purpose of a Jackson-Pratt (JP) drain is not to eliminate the need for wound irrigations. Wound irrigation is a critical step in wound care that helps remove debris, reduce bacterial load, and create an optimal environment for healing. The JP drain helps manage fluid accumulation but does not replace the need for proper wound irrigation.
Choice B reason:
While a JP drain can help manage bleeding by providing a pathway for blood to exit the wound, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the accumulation of fluids such as blood, serous fluid, and other exudates that can impede healing and increase the risk of infection. Managing bleeding typically involves other interventions such as surgical hemostasis techniques.
Choice C reason:
The primary purpose of a Jackson-Pratt drain is to prevent fluid from accumulating in the wound. After surgery, wounds can produce various fluids, including blood and lymphatic fluid. Accumulation of these fluids can delay healing and increase the risk of infection. The JP drain uses gentle suction to draw these fluids away from the wound site, promoting faster healing and reducing the risk of complications.
Choice D reason:
A JP drain is not typically used to provide a means for medication administration. Medications are usually administered through other routes such as oral, intravenous, or through specialized catheters designed for medication delivery. The JP drain is specifically designed for fluid drainage and not for delivering medications.
Correct Answer is A
Explanation
Choice A reason:
The statement “Chamomile may act as a calming agent” is correct. Chamomile is well-known for its calming and sedative effects, which can help reduce anxiety and promote better sleep. It is often used in teas and supplements to help with relaxation and stress relief.
Choice B reason:
The statement “Chamomile has anti-inflammatory properties beneficial for treating skin disorders” is also correct. Chamomile contains compounds that have anti-inflammatory effects, making it useful for treating various skin conditions such as eczema and dermatitis. However, this is not the primary use highlighted in the context of the question.
Choice C reason:
The statement “Chamomile decreases cholesterol levels” is incorrect. There is no substantial evidence to support the claim that chamomile can lower cholesterol levels. Chamomile is more commonly associated with its calming, anti-inflammatory, and digestive benefits.
Choice D reason:
The statement “Chamomile can reduce nausea and vomiting” is correct. Chamomile has been traditionally used to soothe digestive issues, including nausea and vomiting. However, the primary focus in the context of the question is its calming effect.
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