A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?
Document how many inches the tube has been inserted.
Auscultate both lungs for the presence of breath sounds.
Secure the endotracheal tube to prevent dislodgement.
Obtain a chest x-ray to ensure correct tube placement.
The Correct Answer is B
A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.
B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.
C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.
D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.
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Related Questions
Correct Answer is D
Explanation
A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.
B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.
C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.
D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.
Correct Answer is A
Explanation
A. Hypokalemia: Furosemide is a loop diuretic that works by increasing urinary excretion of sodium, chloride, and water, which can lead to potassium loss. Hypokalemia is a common electrolyte imbalance associated with the use of loop diuretics like furosemide. Potassium depletion can cause various complications, including cardiac dysrhythmias, muscle weakness, and fatigue.
B. Hypocalcemia: Furosemide does not directly affect calcium levels, so hypocalcemia is not a common electrolyte imbalance associated with its use.
C. Hypernatremia: Furosemide promotes the excretion of sodium, so hypernatremia (elevated serum sodium levels) is not typically a concern with its use.
D. Hyperkalemia: Furosemide can cause potassium loss, so hyperkalemia is not a risk associated with its use.
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