A young adult is brought to the emergency department after taking a handful of drugs.

The client is unresponsive, so an endotracheal tube (ETT) is inserted.

How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

The correct answer is Choice D.

Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.

Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.

Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.

Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.