A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?

Auscultate lungs for the presence of breath sounds.

Determine that the pulse oximetry is greater than 95%.

Assess baseline level of consciousness.

Assess for the presence of circumoral cyanosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

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Correct Answer is B

Explanation

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

A. A never event. B. A near miss. C. An adverse event. D. A sentinel event.

Correct Answer is C

Explanation

Choice A rationale
A never event refers to a particularly shocking medical error (such as wrong-site surgery) that should never occur. A surgical site infection, while unfortunate, does not fall into this category.
Choice B rationale
A near miss refers to an event that could have had adverse consequences but did not, either by chance or timely intervention. In this case, the client did experience an adverse consequence (the infection), so this term does not apply.
Choice C rationale
An adverse event is an injury caused by medical management rather than the underlying disease. In this case, the surgical site infection that developed after the knee replacement surgery can be considered an adverse event.
Choice D rationale
A sentinel event is a specific type of unexpected occurrence involving death or serious physical or psychological injury. While serious, a surgical site infection requiring prolonged antibiotic therapy and wound care does not typically fall into this category.

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A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Correct Answer is B

Explanation

A 65-year-old client with a history of diabetes mellitus was admitted to the hospital for a scheduled knee replacement surgery. During the postoperative period, the client developed a surgical site infection that required prolonged antibiotic therapy and wound care. This event is categorized as:

Correct Answer is C

Explanation

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A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?