A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?

Document how many inches the tube has been inserted.

Auscultate both lungs for the presence of breath sounds.

Secure the endotracheal tube to prevent dislodgement.

Obtain a chest x-ray to ensure correct tube placement.

Answer and Explanation

The Correct Answer is B

A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.

B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.

C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.

D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.

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Correct Answer is ["B","D","E"]

Explanation

A. Consumes spicy snacks daily: Consuming spicy snacks daily is not a known risk factor for laryngeal cancer. Risk factors for laryngeal cancer typically include tobacco use, alcohol consumption, exposure to certain chemicals, and occupational hazards.

B. Uses flavored chewing tobacco: Chewing tobacco, especially flavored varieties, is a known risk factor for laryngeal cancer. Tobacco contains carcinogenic substances that can damage the cells of the larynx, increasing the risk of cancer development.

C. Employed as x-ray technician: Being employed as an x-ray technician is not a known risk factor for laryngeal cancer. However, prolonged exposure to radiation may increase the risk of other types of cancer, such as lung cancer.

D. Partner smokes cigarettes: Secondhand smoke exposure from a partner who smokes cigarettes is a risk factor for laryngeal cancer. Inhaling tobacco smoke, even indirectly, can expose the individual to carcinogens that may contribute to the development of cancer.

E. Employed as industrial painter: Occupational exposure to certain chemicals, such as those found in paint and industrial solvents, is a known risk factor for laryngeal cancer. Industrial painters may be exposed to carcinogens through inhalation or skin contact, increasing their risk of developing cancer.

A. "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." B. "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." C. "Cysts compress renal tissue, which destroys the kidneys, causing this diagnosis." D. "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis."

Correct Answer is A

Explanation

A. "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." Chronic renal disease often develops as a complication of long-standing

hypertension. Persistent high blood pressure can damage the small blood vessels in the kidneys, reducing blood flow and causing kidney tissue damage over time.

B. "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." This statement describes changes seen in conditions like diabetic nephropathy but is not specific to the development of renal disease in hypertension.

C. "Cysts compress renal tissue, which destroys the kidneys, causing this diagnosis." This statement describes the pathogenesis of polycystic kidney disease, not chronic renal disease due to hypertension.

D. "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis." This statement describes the pathogenesis of glomerulonephritis, not chronic renal disease due to hypertension.

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A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a lecture about cancer prevention strategies for clients seeking to engage in health promotion. The nurse should include which of the following risk factors for the development of laryngeal cancer? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is A

Explanation

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