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.)
Administer pantoprazole as prescribed.
Reposition the endotracheal tube to the opposite side of the mouth daily.
Verify the prescribed ventilator settings daily.
Elevate the head of the bed to at least 30°.
Apply restraints if the client becomes agitated.
Correct Answer : A,B,D
Correct answers: A, B ,D
A. Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.
B. Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.
D. Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.
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Correct Answer is C
Explanation
This is because talking with the client can help reduce anxiety, pain, and isolation, as well as build trust and rapport between the nurse and the client. Talking with the client can also provide an opportunity for education, feedback, and encouragement.
Correct Answer is {"dropdown-group-1":"A"}
Explanation
Tuberculosis is a bacterial infection that affects the lungs and can be transmitted through respiratory droplets. People with HIV are more susceptible to tuberculosis because their immune system is weakened by the virus. Tuberculosis can cause fever, cough, weight loss, and night sweats. The client's vital signs indicate that they have a fever and a high heart rate and respiratory rate, which could be signs of tuberculosis.
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