The nurse notes that a client's ETT, which was at the 21-cm mark, is now at the 22-cm mark, indicating the tube is deeper into the airway than previously. The client is becoming anxious and restless. Which action should the nurse take first?

Notify the healthcare provider.

Obtain a STAT chest x-ray.

Give the client something for anxiety.

Listen to the client's lungs.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Notify the healthcare provider is incorrect as the first action. While the provider must be informed of potential ETT displacement, immediate assessment of the patient’s airway and lung sounds is the priority to ensure safety.

B. Obtain a STAT chest x-ray is incorrect as the first action. A chest x-ray is important for confirming tube placement, but you must first assess for clinical signs of airway compromise or hypoxia before imaging. Waiting for a chest x-ray could delay intervention if the tube has entered a mainstem bronchus.

C. Give the client something for anxiety is incorrect because the anxiety may be a response to hypoxia or airway obstruction, not a primary anxiety issue. Administering medication without assessing the underlying cause could delay critical intervention.

D. Listen to the client's lungs is correct. The first action is to assess breath sounds bilaterally to determine whether the tube has migrated into a mainstem bronchus, which typically causes absent or diminished breath sounds on one side. Immediate assessment of ventilation and oxygenation guides urgent interventions, such as repositioning the ETT, providing oxygen, or calling for help.

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Correct Answer is D

Explanation

Rationale:

A. PEEP helps keep alveoli open to improve oxygenation, but it does not increase the respiratory rate or prevent hypoventilation caused by decreased spontaneous breathing.

B. Pressure support assists spontaneous breaths by decreasing the work of breathing, but if the patient’s spontaneous rate has dropped to 4 breaths/min due to morphine, pressure support alone is insufficient to ensure adequate ventilation.

C. Assist/control ventilation delivers a set rate of mandatory breaths. Setting it at 4 breaths/min would be inadequate because the patient is hypoventilating and may require a higher mandatory rate to maintain adequate gas exchange.

D. SIMV delivers a set number of mandatory breaths, allowing spontaneous breaths in between. Since morphine has depressed the patient’s spontaneous rate from 12 to 4 breaths/min, increasing the mandatory SIMV rate ensures the patient receives adequate total ventilation, preventing hypoventilation and hypercapnia.

A. A pneumectomy patient that had surgery 2 days ago with vital signs RR 20, B/P 150/82, HR 90, and Temp 99. B. A patient recently diagnosed with Guillain-Barré who had numbness in the upper chest with vital signs RR 12, B/P 100/80, HR 90, and Temp 100. C. An appendectomy patient that is resting quietly with vital signs RR 26, B/P 85/60, HR 112, Temp 101.4. D. A patient with restrictive cardiac myopathy with vital signs RR 24, B/P 100/70, HR 110, and Temp 98.6

Correct Answer is A

Explanation

Rationale:
A. A pneumectomy patient that had surgery 2 days ago with vital signs RR 20, B/P 150/82, HR 90, and Temp 99 is correct. This patient is hemodynamically stable, with normal respiratory rate and heart rate, and a low-grade temperature that is not concerning. They are recovering appropriately postoperatively and do not require the intensive monitoring provided in the ICU, making them appropriate for transfer to the floor.

B. A patient recently diagnosed with Guillain-Barré who had numbness in the upper chest with vital signs RR 12, B/P 100/80, HR 90, and Temp 100 is incorrect. Guillain-Barré patients are at risk for rapid respiratory compromise due to neuromuscular weakness. Numbness in the upper chest may indicate early respiratory involvement, so this patient requires continued ICU-level monitoring.

C. An appendectomy patient that is resting quietly with vital signs RR 26, B/P 85/60, HR 112, Temp 101.4 is incorrect. Despite resting, the patient has signs of instability: hypotension, tachycardia, tachypnea, and fever, which may indicate sepsis or hemorrhage. They require ICU care for close monitoring and intervention.

D. A patient with restrictive cardiac myopathy with vital signs RR 24, B/P 100/70, HR 110, and Temp 98.6 is incorrect. Although not febrile, the patient shows mild tachypnea and tachycardia with borderline hypotension, which could signal heart failure exacerbation. ICU monitoring is appropriate to manage potential rapid deterioration.

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The nurse notes that a client's ETT, which was at the 21-cm mark, is now at the 22-cm mark, indicating the tube is deeper into the airway than previously. The client is becoming anxious and restless. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

You are the charge nurse in the ICU and the hospital needs a bed. Which of the following patients can go to the floor?

Correct Answer is A

Explanation

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