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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Step 1: Determine the total daily dose of vancomycin.
- Total daily dose = 50 mg
Step 2: Divide the total daily dose into four equal doses.
- Each dose = 50 mg ÷ 4
- Each dose = 12.5 mg
Step 3: Determine the amount of vancomycin available per capsule.
- Each capsule = 125 mg
Step 4: Calculate the number of capsules needed for each dose.
- Number of capsules per dose = 12.5 mg ÷ 125 mg
- Number of capsules per dose = (12.5 ÷ 125)
- Number of capsules per dose = 0.1
Step 5: Round the answer to the nearest whole number.
- Rounded number of capsules per dose = 0.1 (rounded to 0)
Since 0 capsules is not practical, the nurse should administer 1 capsule per dose to ensure the patient receives the medication.
So, the nurse should administer 1 tabletwith each dose.
Correct Answer is D
Explanation
Choice A reason: Diuretic use
Diuretic use can influence the formation of kidney stones, particularly certain types of diuretics that increase calcium excretion in the urine. However, this is not the most common or significant risk factor compared to others like family history or dietary habits. Diuretics such as loop diuretics can increase the risk of calcium stones by increasing calcium excretion.
Choice B reason: BMI less than 25
A BMI less than 25 is generally considered within the normal range and is not typically associated with an increased risk of urolithiasis. In fact, obesity is a more significant risk factor for kidney stones. Higher BMI is linked to increased excretion of stone-forming substances like calcium and oxalate.
Choice C reason: Hypocalcemia
Hypocalcemia, or low calcium levels in the blood, is not a common risk factor for urolithiasis. In fact, low dietary calcium can increase the risk of kidney stones because it leads to higher oxalate absorption in the gut, which can then form stones in the kidneys. Therefore, hypocalcemia is not typically associated with an increased risk of kidney stones.
Choice D reason: Family history
Family history is a significant risk factor for urolithiasis. If a close relative has had kidney stones, the likelihood of developing them increases. This is due to genetic predispositions that affect factors like urine composition and kidney function. Studies have shown that individuals with a family history of kidney stones are more likely to develop them themselves.
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