To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

auscultate for the presence of bilateral breath sounds.

Use an end-tidal C02 monitor to check for placement in the trachea.

Observe the chest for symmetrical movement with ventilation.

Obtain a portable chest radiograph to check tube placement.

Answer and Explanation

The Correct Answer is C

The nurse should listen over both lung fields to ensure that air entry is present bilaterally, indicating that the tube is correctly positioned in the trachea. This comes after observing chest movements.

B. Using an end-tidal CO2 monitor to check for placement in the trachea in (option B) is incorrect because End-tidal CO2 monitoring can provide confirmation of correct tube placement in the trachea by detecting exhaled CO2 levels. However, it requires additional equipment and setup, which may not be readily available at the bedside or immediately accessible.
C. Observing the chest for symmetrical movement with ventilation is the initial action after placing an endotracheal tube.
D. Obtaining a portable chest radiograph to check tube placement (option D) is incorrect because Chest radiographs are commonly used to confirm endotracheal tube placement, especially for long-term confirmation or if there are concerns about placement. However, obtaining a portable chest radiograph may involve delays and is not the initial action to be taken for immediate verification.
Therefore, the best initial action by the nurse to verify the correct placement of an endotracheal tube (ET) after insertion is to auscultate for the presence of bilateral breath sounds.

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Correct Answer is B

Explanation

Disseminated Intravascular Coagulation (DIC) is a condition characterized by widespread activation of the coagulation system, leading to both excessive clot formation and consumption of clotting factors and platelets. This process can result in both bleeding and thrombosis.
The manifestations mentioned in option B are commonly seen in DIC:
Decreased platelet counts: DIC leads to platelet consumption and destruction, resulting in low platelet counts (thrombocytopenia).
Increased D-dimer: D-dimer is a fibrin degradation product, and its levels are increased DIC due to the breakdown of fibrin clots.
Increased prothrombin time (PT): DIC can lead to the depletion of clotting factors, resulting in prolonged prothrombin time, indicating impaired coagulation.
The other options mentioned do not represent the typical clinical manifestations of DIC:
A. Decreased hematocrit, increased platelet counts, and increased D-dimer in (option A) are incorrect because While platelet counts and D-dimer are increased in DIC, decreased hematocrit is not a characteristic finding.
C. Decreased Antithrombin III, increased platelet counts, and increased fibrinogen in (option C) is incorrect because: Decreased Antithrombin III can be seen in DIC, but increased platelet counts and fibrinogen levels are not specific to DIC.
D. Decreased D-dimer, increased platelet counts, and increased hemoglobin in (option D) is incorrect because Decreased D-dimer and increased hemoglobin are not typical findings in DIC, while increased platelet counts can be seen in some cases.

A. Draw an arterial blood gas (ABG). B. Start insulin drip to maintain blood glucose at 150 mg/dl or lower. C. Give a normal saline bolus IV of 30mL/kg. D. Titrate norepinephrine (Levophed) to keep MAP greater than 65 mm Hg.

Correct Answer is C

Explanation

Septic shock is characterized by inadequate tissue perfusion and hypotension, which can lead to organ dysfunction and failure. The administration of intravenous fluids, such as a normal saline bolus, is the initial priority in the management of septic shock to restore intravascular volume and improve perfusion.
A. Draw an arterial blood gas (ABG) in (option A) is incorrect because: ABG may be ordered to assess the patient's acid-base status and oxygenation, but addressing hypotension and restoring perfusion through fluid administration takes priority.
B. Start insulin drip to maintain blood glucose at 150 mg/dl or lower in (option B) is incorrect because: Hyperglycaemia is commonly observed in critically ill patients, including those with septic shock. While controlling blood glucose is important, it is not the immediate priority compared to addressing hypotension and restoring intravascular volume.
D. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) greater than 65 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor medication used to increase blood pressure and perfusion in septic shock. While it may be necessary for the management of septic shock, fluid resuscitation should be initiated first to optimize intravascular volume before starting vasopressors.
Therefore, the first order that the nurse should accomplish in this scenario is to give a normal saline bolus IV of 30 mL/kg to address the hypotension and restore intravascular volume.

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To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

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Naxlex Comprehensive Predictor Exams

Which of the following clinical manifestations of Disseminated intravascular coagulation (DIC)?

Correct Answer is B

Explanation

A 48-year-old female patient with septic shock presents with a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose of 246 mg/dl. The following have been ordered. Which order will the nurse accomplish first?

Correct Answer is C

Explanation

The emergency department nurse provides care for a 50-year-old male patient with septic shock. The nurse recalls that the renin- angiotensin system is activated during which stage of shock?

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Four hours after mechanical ventilation is initiated for a patient with a suspected drug overdose, the patient's arterial blood gas (ABG) results include a pH of 7.50, Pa0 2 of 80 mm Hg. PaCO2 of 29 mmHg, and HCO3 of 23 mEq/L (23 mmo/L). The nurse will anticipate the need to:

A 66-year-old female patient in septic shock has received fluid resuscitation, but their mean arterial pressure (MAP) is 52 mmHg. The nurse anticipates the administration of which one of the following?

A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Which of the following clinical manifestations is NOT considered part of Beck's triad (classic indications of cardiac tamponade)?

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to