After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
Oxygenate before suctioning.
Auscultate bilateral breath sounds.
Firmly secure the ETT in place.
Suction the ETT every 2 hours.
The Correct Answer is C
A. Oxygenate before suctioning. Pre-oxygenation before suctioning is essential to prevent hypoxia and bradycardia, but it does not directly ensure that the ETT remains in the correct position. This is a general airway management guideline rather than a specific intervention to maintain ETT placement.
B. Auscultate bilateral breath sounds. Auscultation is important for ongoing assessment of lung sounds and oxygenation but does not physically prevent tube displacement. While listening for equal breath sounds helps detect tube migration or mainstem bronchus intubation, it does not secure the ETT in place.
C. Firmly secure the ETT in place. After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
D. Suction the ETT every 2 hours. Routine suctioning is not recommended unless there are indications such as visible secretions, high airway pressures, or decreased oxygenation. Frequent, unnecessary suctioning can cause mucosal trauma, hypoxia, and bradycardia and does not help maintain ETT placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9"]
Explanation
Calculation:
Calculate the dopamine dose in mcg/min:
Dose = 2 mcg/kg/min
Weight = 60 kg
Dose per minute = 2 mcg/kg/min × 60 kg
= 120 mcg/min
Calculate the dopamine dose in mcg/hour:
Dose per hour = 120 mcg/min × 60 min/hour
= 7200 mcg/hour
Convert mcg to mg:
Dose per hour = 7200 mcg/hour / 1000 mcg/mg
= 7.2 mg/hour
Calculate the concentration of dopamine in the IV bag:
Dopamine: 400 mg
Solution: 500 mL
Concentration = 400 mg / 500 mL
= 0.8 mg/mL
Calculate the infusion rate in mL/hour:
Dose per hour: 7.2 mg/hour
Concentration: 0.8 mg/mL
Infusion rate = 7.2 mg/hour / 0.8 mg/mL
= 9 mL/hour
Correct Answer is C
Explanation
A. Oxygenate before suctioning. Pre-oxygenation before suctioning is essential to prevent hypoxia and bradycardia, but it does not directly ensure that the ETT remains in the correct position. This is a general airway management guideline rather than a specific intervention to maintain ETT placement.
B. Auscultate bilateral breath sounds. Auscultation is important for ongoing assessment of lung sounds and oxygenation but does not physically prevent tube displacement. While listening for equal breath sounds helps detect tube migration or mainstem bronchus intubation, it does not secure the ETT in place.
C. Firmly secure the ETT in place. After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
D. Suction the ETT every 2 hours. Routine suctioning is not recommended unless there are indications such as visible secretions, high airway pressures, or decreased oxygenation. Frequent, unnecessary suctioning can cause mucosal trauma, hypoxia, and bradycardia and does not help maintain ETT placement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
