A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?

Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deflation.

Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.

Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.

Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous fluids and nutrition as prescribed.

Choice A: Provide a brightly lit environment is not an intervention that the nurse should take. A brightly lit environment can stimulate the brain and increase intracranial pressure. The nurse should provide a quiet and dimly lit environment to reduce sensory stimuli and promote rest.

Choice B: Elevate the head of the bed is an intervention that the nurse should take. Elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage from the brain and decreasing cerebral blood volume. The nurse should avoid flexing or extending the neck, which can impede blood flow and increase intracranial pressure.

Choice C: Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day is not an intervention that the nurse should take. A high fluid intake can increase intracranial pressure by increasing blood volume and cerebral edema. The nurse should monitor fluid balance and restrict fluid intake as prescribed to maintain normal osmolality and prevent fluid overload.

Choice D: Teach controlled coughing and deep breathing is not an intervention that the nurse should take. Coughing and deep breathing can increase intrathoracic pressure, which can increase intracranial pressure by reducing venous return from the brain. The nurse should avoid activities that can increase intrathoracic pressure, such as straining, sneezing, or blowing the nose. The nurse should also administer oxygen as prescribed to maintain adequate oxygenation and perfusion of the brain.