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 C

Explanation

A. Docusate Sodium (Colace) is a stool softener and is not contraindicated in chronic renal disease.
B. Acetaminophen (Tylenol) is generally safe for use in chronic renal disease, but dosing adjustments may be necessary based on renal function.
C. Meperidine (Demerol) is contraindicated in clients with chronic renal disease because its metabolites can accumulate in renal impairment, leading to neurotoxicity and seizures. It is often replaced with alternative opioid analgesics like morphine or fentanyl in these patients.
D. Atorvastatin (Lipitor) is a statin medication used to lower cholesterol levels and is generally safe in chronic renal disease, although dosing adjustments may be needed depending on the severity of renal impairment.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with chronic renal disease. The nurse should recognize that which of the following medications is contraindicated for clients with chronic renal disease?

Correct Answer is C

Explanation

A client with a history of hypertension and diagnosis of chronic renal disease asks a nurse how the disease occurred. The nurse should accurately respond to the client by making which statement?

Correct Answer is A

Explanation

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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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