Which of the following must be immediately performed in a patient who has just been intubated? (select all that apply)
Auscultate the chest for bilateral breath sounds
Assess the patient's blood glucose
Determine the CO2 level
Obtain a stat PCXR (Portable Chest X ray)
ascites
Correct Answer : A,C,D
A. Auscultate the chest for bilateral breath sounds: Auscultating the chest immediately after intubation ensures that the endotracheal tube is correctly placed in the trachea and not in the esophagus or a bronchus.
B. Assess the patient's blood glucose: Blood glucose monitoring is not immediately necessary following intubation.
C. Determine the CO2 level: Measuring end-tidal CO2 (ETCO2) is crucial to confirm that the tube is in the trachea and that ventilation is occurring effectively.
D. Obtain a stat PCXR (Portable Chest X-ray): A chest X-ray is obtained to confirm the correct placement of the endotracheal tube, ideally 2-3 cm above the carina.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Your liver cannot manufacture bile": The liver can still manufacture bile, but the problem lies in bile flow, not production.
B. "Your pancreas is no longer able to manufacture insulin": This statement refers to diabetes, not cholelithiasis.
C. "Your gall bladder is not contracting properly": While gallbladder dysfunction can cause pain, jaundice specifically occurs due to bile flow obstruction, not just poor contraction.
D. "A gallstone can prevent bile from flowing into the intestines": Gallstones can obstruct the bile ducts, leading to a buildup of bilirubin in the blood, which manifests as jaundice.
Correct Answer is D
Explanation
A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.
B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.
C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.
D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.
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