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 C
Explanation
A. pH 7.25 and HCO₃⁻ 18 mEq/L. A pH of 7.25 is still acidotic, and a bicarbonate level of 18 mEq/L is below the normal range (22–26 mEq/L), indicating persistent metabolic acidosis. This suggests that ketoacidosis is not fully resolved, requiring continued insulin therapy, hydration, and electrolyte management.
B. pH 7.30 and HCO₃⁻ 20 mEq/L. While this shows partial improvement, the pH remains below 7.35, indicating ongoing mild acidosis. The bicarbonate level is still below normal, suggesting that buffering capacity is not yet fully restored. Additional treatment is required to completely normalize acid-base balance.
C. pH 7.38 and HCO₃⁻ 24 mEq/L. A pH of 7.38 falls within the normal range (7.35–7.45), indicating that acidosis has resolved. The bicarbonate level of 24 mEq/L is within normal limits, confirming that the body’s buffering system has been restored. These values suggest that ketoacidosis has resolved, and treatment has been effective.
D. pH 7.20 and HCO₃⁻ 15 mEq/L. A pH of 7.20 indicates severe metabolic acidosis, and a bicarbonate level of 15 mEq/L shows a significant loss of buffering capacity. These values suggest uncontrolled DKA or worsening acidosis, requiring urgent intervention with continued insulin therapy, fluid resuscitation, and electrolyte replacement.
Correct Answer is D
Explanation
A. Creatine kinase-MB (CK-MB). CK-MB is a cardiac enzyme that rises 3-6 hours after myocardial injury and was previously used to diagnose myocardial infarction (MI). However, it is less specific than troponin and can be elevated in skeletal muscle damage, making troponin the preferred biomarker for cardiac injury.
B. Serum glutamic pyruvic transaminase (SGPT). SGPT (also known as alanine aminotransferase [ALT]) is a liver enzyme and is not a primary marker for cardiac injury. While cardiac arrest and hypoxia can lead to liver damage, monitoring cardiac-specific markers is the priority in this scenario.
C. Lactate dehydrogenase (LDH). LDH is a nonspecific marker of tissue damage that can be elevated in cardiac, hepatic, renal, or other organ injuries. It is not cardiac-specific and is no longer used as a primary diagnostic tool for MI.
D. Cardiac troponin. Troponin (T and I) is the most specific and sensitive biomarker for myocardial injury. The presence of ST elevation in multiple leads suggests acute myocardial infarction (MI) as the cause of cardiac arrest. Troponin levels begin to rise within 2-3 hours, peak at 12-24 hours, and remain elevated for 7-10 days, making them the most important laboratory value to monitor for ongoing cardiac damage.
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