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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Power: This term does not specifically align with any section of a SWOT analysis. While it may refer to the influence of stakeholders or organizations in a broader context, it is not a recognized category in the SWOT framework. The focus of power would be more relevant in a different strategic analysis model.
B. Strengths: This section of the SWOT analysis pertains to internal attributes and resources that give the individual or organization an advantage. Examples include skills, experience, and positive relationships. Since the nurse is considering external factors that could hinder career planning, strengths are not the relevant focus here.
C. Opportunities: This part of the SWOT analysis addresses external factors that could provide advantages or beneficial developments for career growth. Opportunities might include advancements in healthcare technology, educational programs, or mentorship. However, the influences hindering career planning are not captured under opportunities.
D. Threats: This section encompasses external factors that pose risks or challenges to achieving goals, such as changes in policies and regulations that could negatively impact career progression. The nurse is correctly identifying these hindrances, which fall under threats, as they represent potential obstacles to successful career planning and development.
Correct Answer is ["15"]
Explanation
Formula:
Volume to administer (mL) = (Desired dose (mEq) / Available concentration (mEq/mL))
Desired dose = (40 mEq / 2 doses)
=20mEq
Available concentration = 6.7 mEq / 5 mL
Calculate the concentration per mL:
6.7 mEq / 5 mL = 1.34 mEq/mL
Volume to administer = 20 mEq / 1.34 mEq/mL
= 14.925... mL
Round to the nearest whole number:
Volume to administer = 15 mL
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