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)

Apply restraints if the client becomes agitated.

Administer pantoprazole as prescribed.

Verify the prescribed ventilator settings daily.

Elevate the head of the bed to at least 30 degrees.

Reposition the endotracheal tube to the opposite side of the mouth daily.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A reason: Applying restraints if the client becomes agitated should be done with caution and only as a last resort. Restraints can increase the risk of injury and should be used according to hospital policy and only when absolutely necessary. Alternative methods to calm the client should be explored first.

Choice B reason: Administering pantoprazole as prescribed is important to prevent stress ulcers and gastrointestinal bleeding, which are common complications in clients receiving mechanical ventilation. Pantoprazole is a proton pump inhibitor that reduces stomach acid production.

Choice C reason: Verifying the prescribed ventilator settings daily is crucial to ensure the client is receiving the correct ventilation support. Regular checks help identify any discrepancies or changes in the client’s condition that may require adjustments to the ventilator settings.

Choice D reason: Elevating the head of the bed to at least 30 degrees helps prevent ventilator-associated pneumonia (VAP) by reducing the risk of aspiration. This position also aids in lung expansion and improves oxygenation.

Choice E reason: Repositioning the endotracheal tube to the opposite side of the mouth daily helps prevent pressure ulcers and sores in the mouth. Regular repositioning reduces the risk of tissue damage and infection.

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Correct Answer is B

Explanation

Choice A reason:

The statement “Treat clients with an antitoxin” is not the primary initial action for anthrax exposure. Antitoxins are used in cases of severe anthrax infection, particularly inhalational anthrax, to neutralize the toxins produced by Bacillus anthracis. However, the first line of treatment for suspected anthrax exposure is antibiotic therapy to eliminate the bacteria.

Choice B reason:

The statement “Administer antibiotic therapy” is correct. The primary treatment for anthrax exposure is the prompt administration of antibiotics. Ciprofloxacin and doxycycline are commonly used antibiotics for treating anthrax. Early antibiotic treatment is crucial to prevent the progression of the disease and reduce the risk of severe complications.

Choice C reason:

The statement “Initiate client decontamination” is not typically necessary for anthrax exposure. Anthrax spores are not easily spread from person to person, and decontamination is generally not required unless there is a significant risk of environmental contamination. The focus should be on administering antibiotics and monitoring the clients for symptoms.

Choice D reason:

The statement “Place the clients in isolation” is incorrect. Anthrax is not contagious and does not spread from person to person. Therefore, isolation is not required for individuals exposed to anthrax. The priority is to provide appropriate medical treatment and monitor for signs of infection.

A. Testing new nurses for exposure to tuberculosis. B. Providing treatment for clients who have chronic obstructive pulmonary disease. C. Performing screening for sexually transmitted infections. D. Administering influenza immunizations at a local health fair.

Correct Answer is B

Explanation

Choice A reason: Testing new nurses for exposure to tuberculosis is an example of secondary prevention. Secondary prevention aims to detect and treat diseases early in their course to prevent progression. Testing for tuberculosis exposure helps identify the disease early so that treatment can begin promptly.

Choice B reason: Providing treatment for clients who have chronic obstructive pulmonary disease is an example of tertiary prevention. Tertiary prevention focuses on managing and improving the quality of life for individuals with chronic diseases. It aims to reduce the impact of the disease and prevent complications.

Choice C reason: Performing screening for sexually transmitted infections is an example of secondary prevention. Screening helps detect infections early, allowing for timely treatment and reducing the spread of the disease.

Choice D reason: Administering influenza immunizations at a local health fair is an example of primary prevention. Primary prevention aims to prevent diseases before they occur by reducing risk factors and promoting health. Immunizations help prevent the onset of influenza.

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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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