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.).

Monitor ETT markings between 22 and 26 cm at teeth line.

Check for capillary refill of 3 seconds or less.

Obtain a portable chest x-ray to verify ETT location.

Assess for symmetrical chest movement.

Auscultate for presence of bilateral breath sounds.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

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Correct Answer is ["B","C","E"]

Explanation

The correct answers are B, C, and E: Gently close the eyes, Place a small pillow under the head, and Remove resuscitation equipment from the room.

Choice B rationale: Gently closing the eyes demonstrates respect for the deceased and can provide a more peaceful appearance for the family.

Choice C rationale: Placing a small pillow under the head is a way to provide comfort and dignity in death, as well as to create a more natural appearance.

Choice E rationale: Removing resuscitation equipment from the room allows for a more serene environment for the family to grieve and say their final goodbyes.

Choice A rationale: Dentures should be left in place, as they contribute to a more natural appearance of the deceased. The exception is if the family requests their removal or if it is the facility's policy to remove dentures.

Choice D rationale: Applying a body shroud is unnecessary when the family has requested to view the body before it is taken to the funeral home. Shrouds are typically used during transportation or if the family does not wish to view the body.

A. Drink electrolyte fluid replacements. B. Give a dose of regular insulin as prescribed. C. Resume normal physical activity. D. Measure urine output over the next 24 hours.

Correct Answer is B

Explanation

Choice A rationale:

Drinking electrolyte fluid replacements may be necessary if the client is dehydrated due to diabetic ketoacidosis (DKA). However, addressing the increased thirst, which is a sign of DKA, should involve insulin administration to correct the underlying problem of high blood sugar.

Choice B rationale:

Giving a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a client with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.

Choice C rationale:

Resuming normal physical activity may not be advisable when a client is experiencing early signs of DKA. Strenuous physical activity can exacerbate hyperglycemia, and the primary focus should be on insulin administration and rehydration.

Choice D rationale:

Measuring urine output over the next 24 hours is important for monitoring hydration status in a client with DKA. However, the immediate priority is to address the increased thirst and hyperglycemia with insulin therapy.

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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.).

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Naxlex Comprehensive Predictor Exams

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is B

Explanation

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

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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 healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

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.).