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 C
Explanation
A. Instruct the client to avoid high-potassium foods: While important for long-term management, it is not the priority when the client is experiencing hyperkalemia, as immediate interventions are necessary to prevent complications.
B. Redraw the potassium to verify results: Redrawing the potassium may be necessary if there is concern about sample contamination or if the result is significantly different from what is expected. However, it is not the priority when the client is at risk of complications from hyperkalemia.
C. Check the client's blood pressure: This is the priority action because hyperkalemia can lead to cardiac dysrhythmias, including potentially life-threatening arrhythmias. Checking the blood pressure helps assess the client's cardiovascular status and any potential effects of hyperkalemia on cardiac function.
D. Obtain a serum sodium level: While monitoring electrolyte levels is important in ESRD, sodium levels are not the priority when the client is experiencing hyperkalemia. Monitoring potassium and managing its effects take precedence.
Correct Answer is D
Explanation
A. Constipation: Constipation is not a common adverse effect of Atenolol, which is a beta- blocker.
B. Cough: Cough is more commonly associated with ACE inhibitors rather than beta-blockers like Atenolol.
C. Tremor: Tremor is not typically an adverse effect of Atenolol; beta-blockers can actually be used to treat essential tremors.
D. Bradycardia: Atenolol, as a beta-blocker, can slow the heart rate, leading to bradycardia, which is a well-documented adverse effect.
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