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 ["B","C","D","E"]
Explanation
Choice A rationale
The material should not be written at a twelfth-grade reading level. Older adults may have varying levels of literacy, and health information should be accessible to all. It is recommended that patient education materials be written at a sixth-grade reading level or lower.
Choice B rationale
Using a 12-point type font can make the material easier to read, especially for older adults who may have vision problems.
Choice C rationale
Including a list with definitions of unfamiliar terms can help older adults understand the material better. Medical jargon can be confusing, and clear explanations of these terms can improve comprehension.
Choice D rationale
Pictures can help illustrate complex ideas and make the material more engaging and easier to understand. Visual aids can be particularly helpful when explaining how to take medication or demonstrating exercises.
Choice E rationale
Using common words with few syllables can make the material more accessible. Complex medical terms can be confusing, and using simple language can help ensure that the information is understood.
Correct Answer is C
Explanation
Choice A rationale
While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.
Choice B rationale
Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.
Choice C rationale
Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.
Choice D rationale
While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.
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.