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 B
Explanation
Choice A rationale:
Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.
Choice B rationale:
This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.
Choice C rationale:
Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.
Choice D rationale:
Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.
Correct Answer is ["30"]
Explanation
The correct answer is 30 mL/hour.
Step 1 is to calculate the total amount of norepinephrine in the IV bag: 4 mg norepinephrine ÷ 1000 mL = 0.004 mg/mL
Step 2 is to convert the patient's weight from pounds to kilograms: 176 pounds ÷ 2.2 = 80 kilograms
Step 3 is to calculate the total amount of norepinephrine the patient will receive per minute: 2 mcg/min × 60 min = 120 mcg/min
Step 4 is to convert micrograms (mcg) to milligrams (mg): 120 mcg ÷ 1000 = 0.12 mg
Step 5 is to calculate the total volume of norepinephrine needed per hour: 0.12 mg ÷ 0.004 mg/mL = 30 mL/hour
Therefore, the nurse should program the infusion pump to deliver 30 mL/hour.
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