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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
The statement “Long attention span” is generally not associated with autism spectrum disorder (ASD). Children with ASD often have difficulty maintaining attention on tasks or activities, especially those that do not interest them. They may exhibit hyperfocus on specific interests but typically struggle with sustained attention in other areas.
Choice B reason:
The statement “Delayed language development” is a common characteristic of ASD. Many children with autism experience delays in speech and language skills. They may have difficulty with verbal communication, understanding language, and using language in social contexts. This delay can vary widely among individuals with ASD.
Choice C reason:
The statement “Speaking with direct eye contact” is not typically associated with ASD. Children with autism often avoid direct eye contact and may find it uncomfortable or overwhelming. They might look away or use peripheral vision instead of making direct eye contact during conversations.
Choice D reason:
The statement “Repetitive behavior” is a hallmark of ASD. Children with autism often engage in repetitive behaviors, such as hand-flapping, rocking, or repeating certain actions or phrases. These behaviors can be a way to self-soothe or cope with sensory overload.
Choice E reason:
The statement “Playing with toys repetitively” is also characteristic of ASD. Children with autism may play with toys in a repetitive manner, such as lining them up, spinning them, or focusing on specific parts of the toy rather than using them in imaginative play. This repetitive play is part of the broader pattern of repetitive behaviors seen in ASD.
Correct Answer is D
Explanation
Choice A reason: Reinforce discharge teaching to clients
While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.
Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs
Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.
Choice C reason: Stock additional unit supplies
Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.
Choice D reason: Focus on providing care that prevents life-threatening emergencies
Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.
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