ATI Maternal Newborn Proctored Exam Related

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A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

  • A. Elevate the head of the bed to at least 30°.
  • B. Apply restraints if the client becomes agitated.
  • C. Administer pantoprazole as prescribed.
  • D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30° helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.