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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Consume a high-protein diet

A high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver, which is already compromised in hepatitis B patients. A balanced diet with adequate protein, carbohydrates, and fats is more appropriate.

Choice B reason: You may donate blood 6 months after completing the medication regimen

Clients with hepatitis B should not donate blood. The hepatitis B virus can be transmitted through blood, and even after completing a medication regimen, the virus can still be present in the blood. Therefore, this statement is incorrect and potentially harmful.

Choice C reason: Take acetaminophen every 4 hours, as needed, for discomfort

Acetaminophen should be used with caution in clients with hepatitis B. The liver metabolizes acetaminophen, and excessive use can lead to liver damage. It is crucial to consult with a healthcare provider before taking any medication, including acetaminophen, to avoid exacerbating liver issues.

Choice D reason: Rest frequently throughout the day

Resting frequently throughout the day is an important part of managing hepatitis B. The liver plays a crucial role in energy metabolism, and when it is compromised, clients may experience fatigue. Adequate rest helps the body recover and manage symptoms more effectively.

A. Dark urine B. Diarrhea C. Urticaria D. Fever

Correct Answer is C

Explanation

Choice A reason:

The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.

Choice B reason:

The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.

Choice C reason:

The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.

Choice D reason:

The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.

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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)

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