A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.
The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.
What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Listen for bilateral breath sounds.

Verify a capillary refill time of less than 3 seconds.

Check that the ETT markings are between 22 and 26 cm at the teeth line.

Observe for symmetrical chest movement.

Arrange for a portable chest x-ray to confirm ETT location.

Answer and Explanation

Correct Answer : A,C,D,E

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.

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Correct Answer is ["C","D"]

Explanation

Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:

C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.

A. Increased pulse rate. B. Skin showing peripheral pallor. C. Clenched fists. D. Increased respiratory rate. E. Restlessness. F. Elevated temperature.

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

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A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Correct Answer is ["C","D"]

Explanation

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

Correct Answer is ["A","C","D","E","F"]

Explanation

Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest.Which action should the nurse take?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.
The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.
What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.