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 ["A","D","E"]

Explanation

Choice A rationale
Culturally incompetent caregivers can be a significant barrier to appropriate communication with clients. Cultural competence involves understanding and respecting the cultural differences and preferences of clients, which can greatly influence how they perceive and respond to healthcare communication.
Choice B rationale
Proper training in healthcare communication is not a barrier, but rather a facilitator of appropriate communication with clients. It equips healthcare professionals with the necessary skills and knowledge to communicate effectively with clients.
Choice C rationale
Excellent health literacy is not a barrier, but rather a facilitator of appropriate communication with clients. Clients with excellent health literacy are better able to understand and engage in healthcare communication.
Choice D rationale
Implicit bias can be a significant barrier to appropriate communication with clients. It refers to the unconscious attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.
Choice E rationale
Lack of diversity can be a significant barrier to appropriate communication with clients. Diversity in the healthcare workforce can enhance the understanding of the cultural and social needs of diverse client populations, thereby improving communication.

A. Establish a benchmark to identify a standard of performance. B. Compare the number of medication errors before and after the implementation of the measures. C. Conduct a study on the time and cost implications of implementing the change. D. Provide a Questionnaire to the staff to quantify their satisfaction with the changes.

Correct Answer is B

Explanation

Choice A rationale
Establishing a benchmark to identify a standard of performance is a crucial step in any quality improvement process. It provides a reference point against which progress can be measured. However, it does not directly evaluate the effectiveness of the implemented measures.
Choice B rationale
Comparing the number of medication errors before and after the implementation of the measures is the most direct and effective method to evaluate the success of the changes. This method provides quantitative data that can clearly show whether the measures have led to a reduction in medication errors.
Choice C rationale
Conducting a study on the time and cost implications of implementing the change can provide valuable information about the efficiency of the measures. However, it does not directly assess their effectiveness in reducing medication errors.
Choice D rationale
Providing a questionnaire to the staff to quantify their satisfaction with the changes can help to assess the acceptance of the measures among the staff. However, staff satisfaction does not necessarily correlate with the effectiveness of the measures in reducing medication errors.

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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

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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?