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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

A. Instruct the client to avoid high-potassium foods. B. Redraw the potassium to verify results. C. Check the client's blood pressure. D. Obtain a serum sodium level.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?

Correct Answer is C

Explanation

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