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. Manage the emotions: Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clarified and during the negotiation process to promote constructive dialogue and prevent escalation of conflict.
B. Breaking the ground rules: Breaking the ground rules refers to violating established guidelines or principles for effective communication and negotiation. This step is not evident in the scenario described.
C. Disregard the conflict: Disregarding the conflict would involve ignoring or avoiding addressing the issues altogether, which is not an appropriate approach to conflict resolution. The scenario indicates that the nurse manager is actively engaged in addressing the conflict.
D. Clarify the problem: In negotiation, clarifying the problem involves identifying and defining the underlying issues or concerns contributing to the conflict. Creating a list of main issues helps ensure that all parties have a clear understanding of what needs to be addressed and provides a foundation for developing potential solutions.
Correct Answer is B
Explanation
A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.
B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.
C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.
D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.
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