A nurse is caring for a client immediately following endotracheal intubation. The nurse should assess the client for complications by performing which of the following priority action?
Auscultate lungs for the presence of breath sounds
Assess baseline level of consciousness
Assess for the presence of circumoral cyanosis
Determine that the pulse oximetry is greater than 95%.
The Correct Answer is A
A. Auscultate lungs for the presence of breath sounds: This is the priority action following endotracheal intubation, as it directly assesses the effectiveness of the intubation. Auscultating the lungs allows the nurse to confirm that the endotracheal tube is properly positioned in the trachea and that air is reaching the lungs. Abnormal breath sounds, such as decreased or absent sounds on one side, may indicate improper placement or complications like a pneumothorax, making this assessment critical for patient safety.
B. Assess baseline level of consciousness: While assessing the client's level of consciousness is important for evaluating their overall neurological status, it is not the immediate priority following intubation. Changes in consciousness can be influenced by various factors, including sedation or hypoxia, but ensuring proper airway placement and ventilation is more urgent to prevent respiratory compromise.
C. Assess for the presence of circumoral cyanosis: Circumoral cyanosis can indicate inadequate oxygenation, but it may not be immediately apparent after intubation. This assessment is important, but it is secondary to confirming that breath sounds are present and that the airway is secure. Identifying airway placement issues is more crucial before evaluating for signs of hypoxia.
D. Determine that the pulse oximetry is greater than 95%: Monitoring pulse oximetry is essential for assessing oxygen saturation and identifying potential hypoxia. However, if the endotracheal tube is not properly placed, the pulse oximetry may not accurately reflect the client’s respiratory status. Therefore, ensuring proper ventilation through auscultation of breath sounds takes precedence over solely relying on pulse oximetry readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. The medication will open the airways: Albuterol is a bronchodilator that works by relaxing the muscles around the airways, leading to dilation and increased airflow. This action helps to relieve symptoms of asthma or chronic obstructive pulmonary disease (COPD), making it easier for the client to breathe. The nurse should emphasize that opening the airways is a primary function of albuterol, providing immediate relief during breathing difficulties.
B. The medication will stimulate the flow of mucus: Albuterol does not primarily stimulate mucus production; rather, its main role is to relax bronchial smooth muscle and open the airways. While effective airway management may lead to improved mucus clearance due to enhanced airflow, albuterol itself does not directly promote mucus secretion. Thus, this statement does not accurately describe the action of the medication.
C. The medication will decrease coughing episodes: By opening the airways and improving airflow, albuterol can help reduce coughing episodes associated with bronchospasm or airway constriction. When the airways are less constricted, the client is less likely to experience the irritative cough often seen in respiratory conditions like asthma. This is an important point for the nurse to convey to help the client understand the medication's benefits.
D. The medication will prevent wheezing: Albuterol can help prevent or relieve wheezing by relaxing the bronchial muscles and facilitating better airflow. Wheezing often occurs when the airways are narrowed or constricted, and by using albuterol, the client can experience fewer wheezing episodes during respiratory distress. The nurse should explain this aspect to reinforce the medication's role in managing asthma or COPD symptoms.
E. The medication will reduce inflammation: Albuterol is not an anti-inflammatory medication; it primarily functions as a bronchodilator. While it can improve breathing by relaxing airway muscles, it does not directly target inflammation in the airways. Inhaled corticosteroids or other anti-inflammatory medications are typically used to address inflammation. Therefore, this response does not accurately reflect the action of albuterol.
Correct Answer is B
Explanation
A. pH 7.55, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 24 mEq/L: This ABG finding indicates respiratory alkalosis, as evidenced by the elevated pH and decreased PaCO2. In progressive COPD, clients typically retain carbon dioxide rather than blow it off, so this finding would not be expected in a patient with chronic respiratory issues.
B. pH 7.30, PaCO2 60 mm Hg, PaO2 70 mm Hg, HCO3 30 mEq/L: This is the most consistent finding for a client with progressive COPD. The low pH indicates acidosis, and the elevated PaCO2 suggests respiratory acidosis due to carbon dioxide retention, a common problem in COPD. The elevated HCO3 indicates a compensatory metabolic response, as the body attempts to retain bicarbonate to buffer the acidosis.
C. pH 7.40, PaCO2 40 mm Hg, PaO2 94 mm Hg, HCO3 22 mEq/L: These values indicate a normal ABG, which would not be expected in a client with progressive COPD. Patients with chronic lung disease typically present with acid-base imbalances due to respiratory failure, so this finding suggests the client is not exhibiting the expected complications of COPD.
D. pH 7.38, PaCO2 45 mm Hg, PaO2 88 mm Hg, HCO3 26 mEq/L: Although these findings show mild acidosis, the PaCO2 is within normal limits, indicating that this patient may not be experiencing significant respiratory failure. In advanced COPD, one would expect to see a higher PaCO2 and more pronounced acidosis, making this option less characteristic of a patient with progressive COPD compared to option B.
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