During endotracheal intubation, the nurse’s priority action to confirm correct tube placement immediately after insertion is to:

Obtain a chest X-ray

Assess bilateral breath sounds and observe for symmetrical chest rise

Check the patient’s oxygen saturation after 10 minutes

Inflate the cuff and secure the tube

Answer and Explanation

The Correct Answer is B

Immediately after endotracheal tube (ETT) insertion, the nurse must confirm correct tube placement to ensure ventilation and oxygenation. Assessing bilateral breath sounds and observing for symmetrical chest rise provides rapid, reliable evidence that the tube is in the trachea rather than the esophagus.

Rationale for Correct Answer

2. Assess bilateral breath sounds and observe for symmetrical chest rise: Auscultation of both lungs and observation of chest movement immediately confirm tracheal placement. Absence of breath sounds on one side may indicate mainstem bronchus intubation, and absent breath sounds bilaterally suggests esophageal placement, both of which require immediate correction.

Rationale for Incorrect Answers

1. Obtain a chest X-ray: A chest X-ray is the gold standard for confirming tube depth but is not immediate. Initial verification must be done at the bedside before ventilating.

3. Check the patient’s oxygen saturation after 10 minutes: Waiting 10 minutes delays recognition of malposition, risking hypoxia. Immediate assessment is required.

4. Inflate the cuff and secure the tube: While necessary for stabilizing the airway, cuff inflation alone does not confirm correct tracheal placement.

Take-Home Points

Immediate confirmation of ETT placement is critical to prevent hypoxia or gastric insufflation.
Bilateral breath sounds and chest rise are rapid bedside assessments for correct placement.
Chest X-ray should follow to verify tube depth, but is not the first step.
Always monitor oxygen saturation and ventilator parameters after securing the tube.

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Correct Answer is B

Explanation

An absence of condensation in the ventilator tubing may indicate that the patient is not receiving adequate tidal volume, that the ventilator circuit is disconnected, or that airway obstruction is present. This finding requires immediate intervention to ensure ventilation and oxygenation are maintained.

Rationale for Correct Answer

2. Absence of condensation in the ventilator tubing: Condensation is a normal indicator of humidified gas flow during mechanical ventilation. A sudden absence may signal tube obstruction, disconnection, or ventilator malfunction, which can lead to rapid hypoxia. Immediate assessment and correction are necessary.

Rationale for Incorrect Answers

1. Cuff pressure of 20 cm H₂O: This is within the recommended safe range (20–25 cm H₂O) to prevent air leaks while minimizing tracheal injury.

3. Small amount of oral secretions present: This is expected in patients with an ET tube and is managed with routine suctioning.

4. Oxygen saturation of 95% on 40% FiO₂: This indicates adequate oxygenation and does not require immediate action.

Take-Home Points

Immediate assessment is required if ventilator indicators suggest airway obstruction or disconnection.
Condensation in the tubing serves as a quick visual cue for airflow and humidification.
Maintain ET tube cuff pressures within 20–25 cm H₂O for safety.
Monitor secretions, oxygen saturation, and ventilator function continuously to prevent complications.

A. Increase functional residual capacity and improve oxygenation. B. Increase FiO₂ in an attempt to wean the patient and avoid O₂ toxicity. C. Determine if the patient is in synchrony with the ventilator or needs to be paralyzed. D. Determine if the patient is able to be weaned and avoid the risk of pneumomediastinum.

Correct Answer is A

Explanation

Positive end-expiratory pressure (PEEP) is added to mechanical ventilation to prevent alveolar collapse at the end of expiration, increase functional residual capacity (FRC), and improve oxygenation. It is particularly useful in patients with acute respiratory distress syndrome (ARDS) or hypoxemic respiratory failure.

Rationale for Correct Answer

1. Increase functional residual capacity and improve oxygenation: PEEP maintains alveolar patency, preventing atelectasis and improving gas exchange. By increasing FRC, more alveoli participate in oxygenation, which enhances PaO₂ and overall tissue oxygen delivery.

Rationale for Incorrect Answers

2. Increase FiO₂ in an attempt to wean the patient and avoid O₂ toxicity: FiO₂ is the fraction of inspired oxygen delivered, not affected by PEEP. PEEP improves oxygenation mechanically without altering FiO₂.

3. Determine if the patient is in synchrony with the ventilator or needs to be paralyzed: Ventilator synchrony is assessed through patient comfort, respiratory effort, and waveforms, not PEEP.

4. Determine if the patient is able to be weaned and avoid the risk of pneumomediastinum: PEEP is not a weaning tool. Excessive PEEP can increase the risk of barotrauma, including pneumomediastinum, rather than prevent it.

Take-Home Points

PEEP improves oxygenation by maintaining alveolar recruitment and increasing functional residual capacity.
Appropriate PEEP levels help reduce shunting and improve gas exchange in hypoxemic patients.
Excessive PEEP can lead to barotrauma and hypotension, so careful titration and monitoring are essential.
PEEP is distinct from FiO₂ adjustments and is part of ventilator management strategies to optimize oxygenation safely.

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During endotracheal intubation, the nurse’s priority action to confirm correct tube placement immediately after insertion is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an endotracheal tube. Which of the following findings requires immediate intervention?

Correct Answer is B

Explanation

The purpose of adding PEEP to positive pressure ventilation is to:

Correct Answer is A

Explanation

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A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching?

During endotracheal intubation, the nurse’s priority action to confirm correct tube placement immediately after insertion is to:

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? Select all that apply

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Which mode of ventilation is used with critically ill patients and allows the patient to self-regulate the rate and depth of spontaneous respirations but may also deliver a preset volume and frequency of breaths?

A patient in acute respiratory failure is receiving ACV with a positive end-expiratory pressure (PEEP) of 10 cm H₂O. What sign alerts the nurse to undesirable effects of increased airway and thoracic pressure?