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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
The educational materials should contain a list with definitions of unfamiliar terms because older clients may not be familiar with medical terminology. Providing definitions can enhance their understanding of the new antihypertensive medications and promote medication adherence.
Choice B rationale:
Writing materials at a twelfth-grade reading level may not be appropriate for older clients. Many older individuals may have lower literacy levels, and using complex language can lead to confusion and hinder comprehension. Simple and clear language is more effective in educating this population.
Choice C rationale:
Using common words with few syllables is important for ensuring that older clients can easily understand the educational materials. Complex language and lengthy words can make it difficult for them to grasp important information about their antihypertensive medications.
Choice D rationale:
Using pictures to help illustrate complex ideas is essential when educating older clients. Visual aids can enhance comprehension and retention of information, especially for individuals who may have cognitive impairments or difficulty with written text.
Choice E rationale:
Printing materials using a 12-point type font is important for ensuring that the text is easy to read for older clients. Smaller fonts can be challenging for individuals with visual impairments, and readability is crucial for effective education.
Correct Answer is A
Explanation
Choice A rationale:
"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.
Choice B rationale:
"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.
Choice C rationale:
"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.
Choice D rationale:
"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.
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