A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.
The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.
What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.
Listen for bilateral breath sounds.
Verify a capillary refill time of less than 3 seconds.
Check that the ETT markings are between 22 and 26 cm at the teeth line.
Observe for symmetrical chest movement.
Arrange for a portable chest x-ray to confirm ETT location.
Correct Answer : A,C,D,E
Choice A rationale
Listening for bilateral breath sounds is a common method to confirm the correct placement of the ETT1. When the ETT is correctly placed, breath sounds should be heard equally on both sides of the chest.
Choice B rationale
Verifying a capillary refill time of less than 3 seconds is not directly related to confirming the placement of an ETT. Capillary refill time is often used to assess peripheral circulation and hydration status, not airway management.
Choice C rationale
Checking that the ETT markings are between 22 and 26 cm at the teeth line is another method to confirm correct ETT placement. These markings help ensure that the ETT is not too far into the trachea, which could cause one lung to be ventilated more than the other.
Choice D rationale
Observing for symmetrical chest movement is a visual confirmation of correct ETT placement. When the ETT is correctly placed, both sides of the chest should rise and fall equally with each breath.
Choice E rationale
Arranging for a portable chest x-ray is considered the gold standard for confirming ETT location. It provides a visual confirmation that the ETT is in the trachea and not in the esophagus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The administration of crystalloid fluids in the first 24 hours following a burn incident promotes fluid resuscitation due to capillary leaking. In the aftermath of a burn, there is a disruption of the normal fluid balance in the body, leading to increased capillary permeability and fluid shifts. This can result in a condition known as burn shock, characterized by decreased blood volume and inadequate tissue perfusion. The administration of crystalloid fluids helps to restore intravascular volume, improve tissue perfusion, and prevent burn shock. It also minimizes burn wound conversion and reduces the incidences of post-burn renal failure, life-threatening electrolyte disturbances, and mortality.
Choice B rationale
While restoration of electrolyte balance is an important aspect of burn management, it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Electrolyte imbalances in burn patients are usually a result of the systemic inflammatory response, fluid shifts, and renal dysfunction that can occur after a burn. These imbalances are typically managed through careful monitoring and specific electrolyte replacement therapies, rather than through the initial administration of crystalloid fluids.
Choice C rationale
Replacement of insensible water loss is another important aspect of burn management, but it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Insensible water loss occurs through evaporation from the burn wound surface and can be significant in burn patients. However, this is typically managed through the maintenance of a humidified environment and specific fluid replacement strategies, rather than through the initial administration of crystalloid fluids.
Choice D rationale
Extension of plasma until blood is available is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. While blood products may be required in the management of severe burns, particularly if there is significant blood loss or hemodynamic instability, the initial focus of fluid resuscitation in burn patients is on the administration of crystalloid solutions to restore intravascular volume and improve tissue perfusion.
Correct Answer is ["A","B","C"]
Explanation
Based on the provided information, the following notations require immediate follow-up:
- Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
- Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
- Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.
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