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 ["A","C","F","H"]

Explanation

Choice A rationale

Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice B rationale

Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.

Choice C rationale

Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.

Choice D rationale

Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.

Choice E rationale

Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.

Choice F rationale

Allowing the client to take a position of comfort can help improve breathing and should be encouraged.

Choice G rationale

Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.

Choice H rationale

Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.

A. Diarrhea and flatulence. B. Abdominal cramps. C. Altered taste. D. Muscle pain.

Correct Answer is D

Explanation

Choice A rationale

Diarrhea and flatulence are common side effects of lovastatin, but they are not typically serious enough to require immediate follow-up.

Choice B rationale

Abdominal cramps can occur with lovastatin use, but they are not usually a sign of a serious problem.

Choice C rationale

Altered taste is a less common side effect of lovastatin and is not typically a cause for immediate concern.

Choice D rationale

Muscle pain can be a sign of a rare but serious side effect of lovastatin called rhabdomyolysis. This condition involves the breakdown of muscle tissue, which can lead to kidney damage. Therefore, this symptom should be prioritized for immediate follow-up.

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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

Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

Correct Answer is ["A","C","F","H"]

Explanation

Which of the following symptoms reported by a patient taking lovastatin should the nurse prioritize for immediate follow-up?

Correct Answer is D

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.