Question

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.)

a. Verify the prescribed ventilator settings daily.
b. Administer pantoprazole as prescribed.
c. Elevate the head of the bed to at least 30.
d. Reposition the endotracheal tube to the opposite side of the mouth daily. e. Apply restraints if the client becomes agitated.

Answer 1

To prevent complications in a mechanically ventilated patient, a nurse should verify ventilator settings daily, administer pantoprazole to prevent stress ulcers, and elevate the head of the bed to reduce pneumonia risk.

Step-by-step explanation:

To prevent complications for a client receiving positive-pressure mechanical ventilation, a nurse should implement several interventions, some of which include:

• Verify the prescribed ventilator settings daily. This ensures that the mechanical ventilation is operating correctly and as prescribed by the healthcare provider.
• Administer pantoprazole as prescribed. Pantoprazole is a proton-pump inhibitor that can prevent stress ulcers, which are a risk due to mechanical ventilation and critical illness.
• Elevate the head of the bed to at least 30 degrees. This helps to reduce the risk of ventilator-associated pneumonia by preventing aspiration.
• Reposition the endotracheal tube to the opposite side of the mouth daily. This helps prevent sores and ulcerations in the mouth and ensures the tube does not cause pressure necrosis.
• Apply restraints if the client becomes agitated. While this is a last resort, it may be necessary to prevent the patient from dislodging the endotracheal tube or interfering with the ventilator.