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 C
Explanation
Choice A reason:
The statement that nonverbal communication conveys less truth than what the client states verbally is incorrect. Nonverbal communication often conveys more truth than verbal communication because it includes body language, facial expressions, and other cues that can reveal a person’s true feelings and intentions. People may say one thing but their nonverbal cues can indicate something different.
Choice B reason:
The statement that the client enacts nonverbal communication consciously is not entirely accurate. While some nonverbal behaviors are conscious, many are subconscious and automatic. For example, facial expressions and body posture often occur without conscious thought and can provide genuine insights into a person’s emotions and state of mind.
Choice C reason:
The client’s sociocultural background influences nonverbal communication is correct. Different cultures have varying norms and interpretations for nonverbal behaviors. For instance, eye contact, gestures, and personal space can have different meanings across cultures. Understanding a client’s sociocultural background helps in accurately interpreting their nonverbal cues.
Choice D reason:
The statement that nonverbal communication is a poor reflection of what the client feels is incorrect. Nonverbal communication is often a very accurate reflection of a person’s feelings. It includes subtle cues like tone of voice, facial expressions, and body language, which can provide deeper insights into a person’s emotional state than words alone.
Correct Answer is B
Explanation
Choice A reason: Cardiac glycosides are primarily used to treat heart conditions such as heart failure and atrial fibrillation. They do not typically affect bone density or contribute to osteoporosis.
Choice B reason: Thyroid hormones can increase the risk of osteoporosis, especially if taken in excess. Over-replacement of thyroid hormone can accelerate bone loss, leading to decreased bone density and increased fracture risk.
Choice C reason: Anticoagulants are used to prevent blood clots but are not generally associated with an increased risk of osteoporosis. Their primary side effects are related to bleeding and bruising.
Choice D reason: NSAIDs (nonsteroidal anti-inflammatory drugs) are used to reduce inflammation and pain. They do not typically affect bone density or contribute to osteoporosis.
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