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:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

Choice A rationale:

Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.

Choice B rationale:

Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.

Choice C rationale:

Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.

Choice D rationale:

Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.