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 ["C","D"]

Explanation

A. Low PaO2. Clients with DKA do not typically have significant hypoxemia unless there is concurrent respiratory compromise. The primary issue in DKA is metabolic acidosis rather than oxygenation.
B. Low lactic acid. Lactic acidosis is not a hallmark of DKA. Instead, DKA is characterized by ketone production from fatty acid metabolism. Elevated lactic acid is more common in conditions like sepsis or tissue hypoxia.
C. Low pH. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, leading to a pH below 7.35. The absence of insulin results in unregulated lipolysis and ketogenesis, significantly lowering blood pH.
D. Low bicarbonate (HCO3-). In metabolic acidosis, bicarbonate acts as a buffer and gets depleted while neutralizing excess acids. Clients with DKA typically have a bicarbonate level below 18 mEq/L (18 mmol/L), confirming metabolic acidosis.
E. High PaCO2. In metabolic acidosis, respiratory compensation leads to hyperventilation (Kussmaul respirations), causing PaCO2 to decrease as the body attempts to blow off excess CO2 to normalize pH.

A. Heparin is infused in less than four hours. B. Systolic blood pressure greater than 120 mm Hg. C. No knee pain upon forced dorsiflexion. D. Intra-arterial cannula remains patent.

Correct Answer is D

Explanation

A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

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

Explanation

A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Correct Answer is D

Explanation

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