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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale
A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.
Choice B rationale
Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.
Choice C rationale
Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.
Choice D rationale
Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.