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 ["A","C"]

Explanation

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

A. Rotator cuff injury B. Humeral fracture C. Concussion D. Knee sprain .

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

Explanation

Choice A rationale

A rotator cuff injury could be a possibility given the patient’s age and the nature of the fall. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, and injuries to this area are common in falls where the shoulder takes the impact.

Choice B rationale

A humeral fracture could also be a possibility. The humerus is the bone in the upper arm, and it can be fractured in falls, especially in older adults who may have weaker bones.

Choice C rationale

A concussion could be a possibility given that the patient hit his head on the wall. Symptoms of a concussion can include nausea and fatigue, which the patient is experiencing.

Choice D rationale

A knee sprain could be a possibility given that the patient is experiencing pain in his right knee. Sprains occur when the ligaments, which are the bands of tissue that hold bones together, are stretched or torn.

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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

Which client statements require follow-up teaching by the nurse? Select all that apply.

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

Explanation

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

Explanation

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

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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.

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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.