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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Breast enlargement is not a known side effect of ginkgo biloba. This herbal supplement is primarily used for its potential benefits in improving cognitive function and circulation. There is no evidence to suggest that ginkgo biloba causes breast enlargement.
Choice B reason:
Decreased alertness is not typically associated with ginkgo biloba. In fact, ginkgo biloba is often taken to enhance cognitive function and alertness. It is believed to improve blood flow to the brain, which can help with memory and mental clarity.
Choice C reason:
Bad breath is not a common side effect of ginkgo biloba. While some herbal supplements can cause changes in breath odor, ginkgo biloba is not known to have this effect. Bad breath is more commonly associated with poor oral hygiene or certain foods.
Choice D reason:
Bleeding gums can be a side effect of ginkgo biloba. This supplement has blood-thinning properties, which can increase the risk of bleeding. People taking ginkgo biloba should be cautious if they are also taking other blood-thinning medications or have conditions that predispose them to bleeding.
Correct Answer is D
Explanation
Choice A reason:
Naproxen is classified as a pregnancy category B medication during the first and second trimesters but becomes category D in the third trimester due to potential risks to the fetus. It is generally advised to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen during pregnancy unless specifically recommended by a healthcare provider.
Choice B reason:
Aspirin is not considered safe during pregnancy, especially in higher doses. It is classified as category D in the third trimester due to risks such as premature closure of the ductus arteriosus and potential bleeding complications. Low-dose aspirin may be prescribed in specific cases, but it is not generally recommended as an over-the-counter option for pregnant women.
Choice C reason:
Ibuprofen, like naproxen, is an NSAID and is classified as category B during the first and second trimesters but category D in the third trimester. It is generally advised to avoid ibuprofen during pregnancy due to potential risks to the fetus, particularly in the later stages of pregnancy.
Choice D reason:
Acetaminophen is classified as a pregnancy category B medication and is considered safe for use during all trimesters of pregnancy. It is the preferred over-the-counter analgesic and antipyretic for pregnant women due to its safety profile. Acetaminophen does not carry the same risks as NSAIDs and is widely used to manage pain and fever during pregnancy.
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