To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

auscultate for the presence of bilateral breath sounds.

Use an end-tidal C02 monitor to check for placement in the trachea.

Observe the chest for symmetrical movement with ventilation.

Obtain a portable chest radiograph to check tube placement.

Answer and Explanation

The Correct Answer is C

The nurse should listen over both lung fields to ensure that air entry is present bilaterally, indicating that the tube is correctly positioned in the trachea. This comes after observing chest movements.

B. Using an end-tidal CO2 monitor to check for placement in the trachea in (option B) is incorrect because End-tidal CO2 monitoring can provide confirmation of correct tube placement in the trachea by detecting exhaled CO2 levels. However, it requires additional equipment and setup, which may not be readily available at the bedside or immediately accessible.
C. Observing the chest for symmetrical movement with ventilation is the initial action after placing an endotracheal tube.
D. Obtaining a portable chest radiograph to check tube placement (option D) is incorrect because Chest radiographs are commonly used to confirm endotracheal tube placement, especially for long-term confirmation or if there are concerns about placement. However, obtaining a portable chest radiograph may involve delays and is not the initial action to be taken for immediate verification.
Therefore, the best initial action by the nurse to verify the correct placement of an endotracheal tube (ET) after insertion is to auscultate for the presence of bilateral breath sounds.

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Correct Answer is C

Explanation

Hemorrhagic shock is characterized by severe blood loss, leading to inadequate tissue perfusion and hypovolemia. The primary goal in the initial management of hemorrhagic shock is to restore intravascular volume and improve tissue perfusion. Administering intravenous fluids, such as normal saline solution, is a critical intervention to address hypovolemia and improve blood pressure.
A. Give Plasmanate 1 unit now in (option A) is incorrect because: Plasmanate is a plasma-derived product used to replace coagulation factors. While it may be necessary to address coagulation abnormalities, administering intravenous fluids to restore volume takes priority over specific blood products.
B. Prepare for endotracheal intubation in (option B) is incorrect because Endotracheal intubation may be required in cases of impending respiratory failure or compromised airway, but it should not be the first action in addressing hypovolemic shock.
D. Type and crossmatch for 4 units of packed red blood cells (PRBCs) in (option D) is incorrect because transferring packed red blood cells is an important intervention to address blood loss and improve oxygen-carrying capacity. However, before administering blood products, it is crucial to stabilize the patient's hemodynamics through fluid resuscitation.
Therefore, in a patient with hemorrhagic shock, the nurse's first priority among the given options is to give normal saline solution of 250 mL/hr to restore intravascular volume and improve tissue perfusion.

A. Administer hydrocortisone (Solu-Cortef) 100 mg IV. B. Give PRN furosemide (Lasix) 40 mg IV. C. Increase normal saline infusion to 250 mL/hr. D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

Correct Answer is C

Explanation

In septic shock, one of the key goals of management is to restore and maintain adequate intravascular volume. However, in this case, the patient's urine output is low (30 mL/hr for the past 3 hours), suggesting inadequate renal perfusion and potential fluid overload.
Administering additional normal saline at an increased rate (250 mL/hr) without addressing the low urine output could potentially exacerbate fluid overload and further compromise the patient's condition.
A. Administer hydrocortisone (Solu-Cortef) 100 mg IV in (option A) is incorrect because: Hydrocortisone is commonly used in septic shock to help stabilize blood pressure and modulate the inflammatory response.
B. Giving PRN furosemide (Lasix) 40 mg IV in (option B) is incorrect because Furosemide, a loop diuretic, can be administered as needed to address fluid overload or to increase urine output if there is evidence of volume overload.
D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor commonly used in septic shock to increase systemic vascular resistance and maintain adequate blood pressure.

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To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wed pressure are low. Which order by the health care provider will the nurse question?

Correct Answer is C

Explanation

Which of the following is the most accurate assessment of tissue perfusion in a patient in shock?

Which assessment information obtained by the nurse when caring for a COPD patient receiving mechanical ventilation indicates the need for suctioning?

The common denominator of all shock states is which one of the following?

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

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When caring for a patient weighing 60 kg who has just been admitted with septic shock, which of these assessment data greatest concern to the nurse?

An emergency room nurse cares for a patient admitted with a 50% burn injury. The patient weighs 90 kg. Using the Parkland formula, calculate the rate (1st 8 hrs.) at which the nurse would infuse intravenous fluid resuscitation. (Record your answer using a whole number.)