A patient is receiving linezolid IV for nosocomial pneumonia.
Which assessment finding is most important for the nurse to report to the healthcare provider?

Choice A rationale

Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.

Choice B rationale

Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.

Choice C rationale

Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.

Choice D rationale

Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.

Choice A rationale

Listening for bilateral breath sounds is a common method to confirm the correct placement of the ETT1. When the ETT is correctly placed, breath sounds should be heard equally on both sides of the chest.

Choice B rationale

Verifying a capillary refill time of less than 3 seconds is not directly related to confirming the placement of an ETT. Capillary refill time is often used to assess peripheral circulation and hydration status, not airway management.

Choice C rationale

Checking that the ETT markings are between 22 and 26 cm at the teeth line is another method to confirm correct ETT placement. These markings help ensure that the ETT is not too far into the trachea, which could cause one lung to be ventilated more than the other.

Choice D rationale

Observing for symmetrical chest movement is a visual confirmation of correct ETT placement. When the ETT is correctly placed, both sides of the chest should rise and fall equally with each breath.

Choice E rationale

Arranging for a portable chest x-ray is considered the gold standard for confirming ETT location. It provides a visual confirmation that the ETT is in the trachea and not in the esophagus.