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.).

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.

The correct answer is Choice C: Assign the remainder of medication administration to another Practical Nurse (PN) who is performing treatments.

Choice A reason: Denying the medication aide’s request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide’s request and find an appropriate solution that ensures patient safety and well-being.

Choice B reason: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.

Choice C reason: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse’s responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.

Choice D reason: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.