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 A

Explanation

Choice A reason: Have you had a recent influenza infection?

Guillain-Barré syndrome (GBS) is often preceded by an infection, most commonly respiratory or gastrointestinal infections. Influenza is a significant respiratory infection that can trigger GBS. Asking about recent influenza infection helps in identifying a potential cause of the syndrome. According to the Mayo Clinic, many cases of GBS occur after a respiratory or gastrointestinal infection1. Therefore, this question is crucial in the assessment of a client with suspected GBS.

Choice B reason: Have you traveled overseas recently?

While travel history can be relevant in diagnosing various conditions, it is less directly related to Guillain-Barré syndrome. GBS is not typically associated with travel but rather with infections that can occur anywhere. Therefore, this question is less pertinent compared to asking about recent infections.

Choice C reason: Do you have a history of chronic alcohol abuse?

Chronic alcohol abuse can lead to various neurological conditions, but it is not specifically linked to Guillain-Barré syndrome. GBS is an acute condition often triggered by an infection, not by chronic alcohol use. Thus, while this question might be relevant in a broader neurological assessment, it is not directly related to GBS.

Choice D reason: Are you taking a multivitamin?

The use of multivitamins is generally not related to the development of Guillain-Barré syndrome. This question does not help in identifying the cause or confirming the diagnosis of GBS. It is more relevant to a general health assessment rather than a specific inquiry for GBS.

A. Aplastic anemia results in an increased rate of RBC destruction. B. Aplastic anemia is associated with a decreased intake of iron. C. Aplastic anemia results from decreased bone marrow production of RBCs. D. Aplastic anemia results in an inability to absorb vitamin B12.

Correct Answer is C

Explanation

Choice A reason: Aplastic anemia results in an increased rate of RBC destruction

Aplastic anemia does not result from an increased rate of red blood cell (RBC) destruction. Instead, it is characterized by the bone marrow’s inability to produce sufficient new blood cells, including RBCs, white blood cells, and platelets. This condition leads to pancytopenia, a deficiency of all types of blood cells.

Choice B reason: Aplastic anemia is associated with a decreased intake of iron

Aplastic anemia is not typically associated with a decreased intake of iron. Iron deficiency anemia is a different condition where the body lacks enough iron to produce hemoglobin. Aplastic anemia, on the other hand, is due to the failure of the bone marrow to produce adequate blood cells.

Choice C reason: Aplastic anemia results from decreased bone marrow production of RBCs

This statement is correct. Aplastic anemia occurs when the bone marrow fails to produce enough new blood cells. This can be due to various factors, including autoimmune disorders, exposure to toxic chemicals, certain medications, and viral infections. The decreased production of RBCs, along with other blood cells, leads to the symptoms associated with aplastic anemia.

Choice D reason: Aplastic anemia results in an inability to absorb vitamin B12

Aplastic anemia is not related to the absorption of vitamin B12. Pernicious anemia is the condition associated with an inability to absorb vitamin B12 due to a lack of intrinsic factor. Aplastic anemia is specifically related to the bone marrow’s failure to produce sufficient blood cells.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (G85). Which of the following questions should the nurse ask the client?

Correct Answer is A

Explanation

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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