A nurse is caring for a client immediately following endotracheal intubation. The nurse should assess the client for complications by performing which of the following priority action?
Auscultate lungs for the presence of breath sounds
Assess baseline level of consciousness
Assess for the presence of circumoral cyanosis
Determine that the pulse oximetry is greater than 95%.
The Correct Answer is A
A. Auscultate lungs for the presence of breath sounds: This is the priority action following endotracheal intubation, as it directly assesses the effectiveness of the intubation. Auscultating the lungs allows the nurse to confirm that the endotracheal tube is properly positioned in the trachea and that air is reaching the lungs. Abnormal breath sounds, such as decreased or absent sounds on one side, may indicate improper placement or complications like a pneumothorax, making this assessment critical for patient safety.
B. Assess baseline level of consciousness: While assessing the client's level of consciousness is important for evaluating their overall neurological status, it is not the immediate priority following intubation. Changes in consciousness can be influenced by various factors, including sedation or hypoxia, but ensuring proper airway placement and ventilation is more urgent to prevent respiratory compromise.
C. Assess for the presence of circumoral cyanosis: Circumoral cyanosis can indicate inadequate oxygenation, but it may not be immediately apparent after intubation. This assessment is important, but it is secondary to confirming that breath sounds are present and that the airway is secure. Identifying airway placement issues is more crucial before evaluating for signs of hypoxia.
D. Determine that the pulse oximetry is greater than 95%: Monitoring pulse oximetry is essential for assessing oxygen saturation and identifying potential hypoxia. However, if the endotracheal tube is not properly placed, the pulse oximetry may not accurately reflect the client’s respiratory status. Therefore, ensuring proper ventilation through auscultation of breath sounds takes precedence over solely relying on pulse oximetry readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
Formula:
Volume to administer (mL) = (Desired dose (mg) / Available concentration (mg/mL))
Desired dose = 1.6 mg
Available concentration = 2 mg / 5 mL
Calculate the concentration per mL:
2 mg / 5 mL = 0.4 mg/mL
Volume to administer = 1.6 mg / 0.4 mg/mL
= 4 mL
The nurse should administer 4 mL per dose.
Correct Answer is B
Explanation
A. Cultural differences. While cultural beliefs may influence end-of-life decisions, the primary issue in this scenario is not cultural misunderstanding but rather the conflict between the client’s documented wishes and the family's demands. Cultural differences typically pertain to variations in values, traditions, or beliefs, rather than legal and ethical dilemmas regarding patient autonomy.
B. Ethical conflict. The nurse is experiencing moral distress due to a conflict between ethical principles—specifically, the principle of patient autonomy (respecting the client’s right to make their own healthcare decisions) and beneficence (providing care that benefits the client). The client’s living will, a legally binding document, states Do Not Resuscitate (DNR), yet the children are insisting on full resuscitation. The nurse’s distress arises from witnessing actions that contradict the client’s wishes and ethical nursing responsibilities.
C. Competition between groups. There is no indication that different groups, such as healthcare teams or family members, are competing for resources or control. The conflict stems from an ethical dilemma rather than rivalry or organizational disputes.
D. Scarcity, safety, and security. This situation does not involve limited resources, threats to safety, or security concerns. The distress is rooted in the ethical dilemma of honoring the client’s advance directive versus the family’s insistence on aggressive resuscitation measures.
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