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 C

Explanation

Choice A reason:

The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.

Choice B reason:

The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.

Choice C reason:

The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.

Choice D reason:

The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.

A. Place the shoulder harness straps below the level of the newborn’s armpits. B. Keep the car seat rear-facing until the newborn can sit unsupported. C. Place the retainer clip across the newborn’s abdomen. D. Position the newborn at a 45-degree angle in the car seat.

Correct Answer is D

Explanation

Choice A reason: Placing the shoulder harness straps below the level of the newborn’s armpits is incorrect. The shoulder harness straps should be at or below the level of the newborn’s shoulders to ensure a snug and secure fit.

Choice B reason: Keeping the car seat rear-facing until the newborn can sit unsupported is incorrect. The car seat should remain rear-facing until the child reaches the maximum height or weight limit specified by the car seat manufacturer, which is typically around 2 years of age.

Choice C reason: Placing the retainer clip across the newborn’s abdomen is incorrect. The retainer clip should be positioned at the level of the newborn’s armpits to ensure the harness straps are properly aligned and to prevent the baby from slipping out of the harness.

Choice D reason: Positioning the newborn at a 45-degree angle in the car seat is correct. This angle helps keep the newborn’s airway open and reduces the risk of airway obstruction. It also ensures that the baby is securely positioned in the seat.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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