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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The statement “You will be fitted for your permanent prosthesis at the time of surgery” is incorrect. Typically, a temporary prosthesis is used initially after surgery. The permanent prosthesis is fitted later, once the residual limb has healed and any swelling has subsided. This process ensures a better fit and comfort for the client.
Choice B reason:
The statement “You will do muscle strengthening exercises in advance of getting your prosthesis” is correct. Muscle strengthening exercises are crucial for preparing the residual limb and the rest of the body for the use of a prosthesis. These exercises help improve balance, strength, and mobility, which are essential for successful prosthesis use.
Choice C reason:
The statement “The structure of the prosthesis will be adjustable depending on what shoe you are wearing” is incorrect. While some prostheses can accommodate different types of footwear, the structure of the prosthesis itself is not typically adjustable. Clients may need to have different prosthetic feet or adjustments made by a prosthetist to accommodate various shoes.
Choice D reason:
The statement “A special pressure dressing will remain in place even when your limb is healed to cushion your prosthesis” is incorrect. A special pressure dressing, also known as a compression dressing, is used initially after surgery to reduce swelling and shape the residual limb. Once the limb has healed, the dressing is no longer needed. The prosthesis itself will have a socket designed to fit the residual limb comfortably.
Correct Answer is D
Explanation
Choice A reason: Low-protein, low-potassium diet
A low-protein, low-potassium diet is not typically recommended for acute glomerulonephritis. While protein intake may need to be moderated to reduce the workload on the kidneys, potassium restriction is usually not necessary unless there is hyperkalemia (high potassium levels) present. The primary dietary focus should be on managing fluid and sodium intake to control edema and hypertension.
Choice B reason: Regular diet, no added salt
A regular diet with no added salt is a step in the right direction but may not be sufficient for managing acute glomerulonephritis with significant edema. Sodium restriction is crucial to help reduce fluid retention and control blood pressure. Therefore, a more stringent low-sodium diet is often necessary.
Choice C reason: Low-carbohydrate, low-protein diet
A low-carbohydrate, low-protein diet is not appropriate for managing acute glomerulonephritis. Carbohydrate intake does not directly impact kidney function in this context, and protein intake should be moderated rather than severely restricted. The focus should be on sodium and fluid management.
Choice D reason: Low-sodium, fluid-restricted diet
A low-sodium, fluid-restricted diet is the most appropriate choice for a client with acute glomerulonephritis and peripheral edema. Reducing sodium intake helps to minimize fluid retention and control blood pressure, while fluid restriction helps to prevent further edema and manage the workload on the kidneys. This dietary approach is essential for managing the symptoms and complications associated with acute glomerulonephritis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
