A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse include in the plan of care?

Rationale: A. Analgesics for clients on mechanical ventilation should not be given on a fixed schedule without assessment. Pain and sedation needs should be individualized and based on continuous assessment (e.g., pain scales, sedation scales such as RASS). Routine scheduled dosing every 8 hours may lead to over-sedation or under-treatment. B. Suctioning should be performed as needed, not on a routine schedule. Indications include visible or audible secretions, decreased oxygen saturation, increased peak airway pressures, or signs of respiratory distress. Routine suctioning every 4 hours can cause mucosal trauma, hypoxia, and infection. C. Elevating the head of the bed (typically 30–45 degrees or higher if tolerated) improves lung expansion, enhances oxygenation, reduces the risk of aspiration, and decreases the risk of ventilator-associated pneumonia (VAP). This is a standard evidence-based intervention for clients receiving mechanical ventilation. D. While daily weight monitoring is often important in critically ill clients to assess fluid balance, especially in those receiving mechanical ventilation, weekly weights are too infrequent. Fluid shifts in critically ill patients can occur rapidly, so more frequent monitoring is typically required.