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

Explanation

Choice A rationale

Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.

Choice B rationale

Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.

Choice C rationale

The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.

Choice D rationale

Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.

A. Canned chicken broth with barley. B. Tomato juice and gluten-free crackers. C. Plain baked sweet potato. D. Dill pickles and black olives.

Correct Answer is C

Explanation

Choice A rationale

Canned chicken broth with barley is not the best choice for a patient with hypertension. Canned foods, including chicken broth, are often high in sodium, which can raise blood pressure.

Choice B rationale

Tomato juice and gluten-free crackers may seem like a healthy option, but tomato juice can be high in sodium. While gluten-free crackers can be part of a healthy diet, they don’t offer any specific benefits for controlling hypertension.

Choice C rationale

A plain baked sweet potato is an excellent choice for a patient with hypertension. Sweet potatoes are high in potassium, which can help lower blood pressure. They’re also a good source of fiber and are naturally low in sodium.

Choice D rationale

Dill pickles and black olives are both high in sodium, which can raise blood pressure. Therefore, they’re not a good choice for someone with hypertension.

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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

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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.