The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?

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.

Choice A rationale

The material should not be written at a twelfth-grade reading level. Older adults may have varying levels of literacy, and health information should be accessible to all. It is recommended that patient education materials be written at a sixth-grade reading level or lower.

Choice B rationale

Using a 12-point type font can make the material easier to read, especially for older adults who may have vision problems.

Choice C rationale

Including a list with definitions of unfamiliar terms can help older adults understand the material better. Medical jargon can be confusing, and clear explanations of these terms can improve comprehension.

Choice D rationale

Pictures can help illustrate complex ideas and make the material more engaging and easier to understand. Visual aids can be particularly helpful when explaining how to take medication or demonstrating exercises.

Choice E rationale

Using common words with few syllables can make the material more accessible. Complex medical terms can be confusing, and using simple language can help ensure that the information is understood.