After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?

Obtain a chest x-ray to verify endotracheal tube location.

Call the respiratory therapist (RT) to verify tube placement.

Instill normal saline into the endotracheal tube for suctioning.

Auscultate for breath sounds bilaterally in all lung fields.

Answer and Explanation

The Correct Answer is D

A. Obtain a chest x-ray to verify endotracheal tube location. A chest x-ray is the gold standard for confirming ETT placement, but it is not the first step. Immediate bedside assessment is needed to ensure the tube is correctly positioned before relying on imaging. If the tube is misplaced in the esophagus, waiting for an x-ray could delay necessary corrections.
B. Call the respiratory therapist (RT) to verify tube placement. The nurse should first perform a rapid bedside assessment before consulting the RT. While RTs assist in confirming placement, the nurse is responsible for the initial verification of breath sounds, chest rise, and end-tidal CO₂ (ETCO₂) readings. Any concerns should be addressed immediately.
C. Instill normal saline into the endotracheal tube for suctioning. Instilling saline before suctioning is not recommended, as it can promote aspiration, decrease oxygenation, and increase infection risk. The priority is confirming that the tube is properly placed before performing any interventions such as suctioning.
D. Auscultate for breath sounds bilaterally in all lung fields. The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.

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Correct Answer is A

Explanation

A. Respirations are shallow, labored, and 14 breaths/minute. A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
B. Has flaccid upper and lower extremities. Flaccid paralysis is an expected finding immediately after a high spinal cord injury due to spinal shock. While this condition requires ongoing monitoring, it is not an immediate life-threatening emergency like respiratory distress.
C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. These vital signs are within normal limits and do not indicate hemodynamic instability. Neurogenic shock, which can occur with high spinal injuries, typically presents with hypotension and bradycardia, but this client’s current BP and HR are stable.
D. Is unable to feel sensation in the arms and hands. Loss of sensation is expected with a cervical spinal cord injury due to nerve pathway disruption. While this finding is significant, it does not require immediate intervention compared to respiratory distress, which is the most urgent priority.

A. Respiratory rate of 26 breaths/minute. B. Heart rate of 112 beats/minute. C. Temperature of 96.1° F (35.6°C). D. White blood count of 14,000/mm3 (14 x 109/L). E. Hemoglobin of 12.8 gram/dL (7.94 mmol/L).

Correct Answer is ["A","B","C","D"]

Explanation

A. Respiratory rate of 26 breaths/minute. A respiratory rate ≥22 breaths/minute meets the SIRS criteria and indicates systemic inflammation or respiratory distress. In pneumonia, increased breathing effort may result from hypoxia or infection-related metabolic demands. Persistent tachypnea suggests worsening sepsis and requires urgent intervention.
B. Heart rate of 112 beats/minute. A heart rate ≥90 beats/minute is a SIRS criterion, often caused by infection, hypoxia, or systemic inflammation. In pneumonia, tachycardia may result from fever, pain, or compensatory mechanisms due to decreased oxygenation. An elevated heart rate in sepsis may indicate progressing hemodynamic instability.
C. Temperature of 96.1° F (35.6°C). Hypothermia (<96.8°F/36°C) is a SIRS criterion and may indicate severe sepsis or systemic inflammatory response. While fever is a common response, low temperature suggests immune system dysfunction. Hypothermia in sepsis is linked to poor prognosis and increased mortality risk.
D. White blood count of 14,000/mm³ (14 x 10⁹/L). A WBC >12,000/mm³ or <4,000/mm³ meets SIRS criteria and indicates infection-related immune activation. Elevated WBCs suggest an active inflammatory response to pneumonia. A rising WBC count may indicate worsening infection or ineffective immune control.
E. Hemoglobin of 12.8 gram/dL (7.94 mmol/L). Hemoglobin levels within the normal range (12-16 g/dL) do not indicate SIRS or sepsis progression. While anemia can develop in chronic illness or bleeding, this value does not contribute to SIRS classification. Monitoring oxygenation and perfusion is more relevant in pneumonia cases.

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After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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