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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
PEEP does not decrease trapped oxygen in the alveoli. Instead, it helps to increase the volume of gas remaining in the lungs at the end of expiration, which can improve oxygenation.
Choice B rationale
PEEP does not directly promote independent breathing efforts. It is a mode of mechanical ventilation used to support a patient’s breathing.
Choice C rationale
PEEP keeps the airways and small lung spaces open by increasing the pressure in the lungs at the end of expiration. This can prevent alveolar collapse and improve oxygenation in patients with conditions like ARDS23.
Choice D rationale
While PEEP can be used in the process of weaning a patient off mechanical ventilation, its primary benefit is not facilitating weaning. It is used to improve oxygenation and prevent alveolar collapse.
Correct Answer is B
Explanation
Choice A rationale
A chocolate milkshake may be soothing, but it is not the best choice for a patient with bacterial pharyngitis due to its high sugar content, which can promote bacterial growth.
Choice B rationale
Chicken noodle soup is a good choice as it is soothing, easy to swallow, and provides necessary nutrients.
Choice C rationale
Vanilla ice cream, while soothing, is not the best choice due to its high sugar content.
Choice D rationale
Fruit-flavored popsicles, while soothing, are not the best choice due to their high sugar content.
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