A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply)

Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.

Choice A reason: Decreasing fluid intake to firm stools is incorrect, as adequate hydration (2-3 L/day) is essential to prevent constipation, especially with opioids like oxycodone, which slow intestinal motility. Low fluid intake hardens stools, exacerbating constipation risk by reducing water content in the colon, indicating a misunderstanding of prevention strategies.
Choice B reason: Increasing dietary fiber intake (25-35 g/day) adds bulk to stools, stimulating peristalsis and counteracting opioid-induced slowed motility. Soluble and insoluble fiber, found in fruits, vegetables, and whole grains, promotes regular bowel movements. This statement reflects correct understanding of dietary measures to prevent constipation during opioid therapy.
Choice C reason: Taking a laxative only when constipated is reactive, not preventive. Opioids like oxycodone commonly cause constipation by reducing peristalsis via mu-opioid receptors in the gut. Prophylactic use of stool softeners or laxatives is recommended to maintain regular bowel movements, making this statement incorrect as it lacks a preventive approach.
Choice D reason: Exercising less to conserve energy worsens constipation, as physical activity stimulates intestinal motility, countering opioid-induced slowing. Regular movement, like walking, promotes bowel function by enhancing peristalsis and blood flow to the gut. This statement indicates a misunderstanding, as reduced activity increases constipation risk.