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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.

Choice B rationale

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.

Choice C rationale

Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.

Choice D rationale

Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

A. Advise the parent to reduce the infant’s fruit intake for 24 hours. B. Recommend the parent to clean with soap and water at each diaper change. C. Instruct the parent to change the child’s diaper more frequently. D. Encourage the parent to apply lotion with each diaper change.

Correct Answer is C

Explanation

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

Correct Answer is B

Explanation

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Correct Answer is C

Explanation

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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.