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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Naxlex Comprehensive Predictor Exams
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