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.

Answer and Explanation

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

An escharotomy is a surgical procedure that involves making incisions in the eschar, which is the hard, blackened tissue that forms over a severe burn wound. The eschar can restrict blood flow and cause compartment syndrome, which can lead to tissue necrosis and nerve damage. By cutting through the eschar, the pressure is relieved and circulation is restored. This procedure does not involve removing the dead tissue, which is done by debridement or hydrotherapy. A skin graft is a different procedure that involves transplanting healthy skin from another site to cover a burn wound.

A. "Drink at least 8 ounces of water when you take the pyrazinamide tablet." B. "Take isoniazid with an antacid." C. "Expect your sputum cultures to be negative after 6 months of therapy." D. "Provide a sputum specimen every 2 weeks to the clinic for testing."

Correct Answer is A

Explanation

Pyrazinamide is a medication used to treat tuberculosis that can cause renal damage and crystal formation in the urine if not adequately hydrated. The client should also avoid alcohol and have regular liver function tests while taking this medication. Isoniazid should not be taken with antacids, as they can decrease its absorption and effectiveness. Sputum cultures are expected to be negative after 2 months of therapy, not 6 months. Providing a sputum specimen every 2 weeks is not an instruction for the client, but a part of the monitoring process by the health care team.

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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 in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is C

Explanation

A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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