The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.)
a. Auscultation of air over the epigastrium
b. Equal bilateral breath sounds upon auscultation
c. Position above the carina verified by chest x-ray
d. Positive detection of carbon dioxide (CO2) through CO2 detector devices
B, C, D
The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea.
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A critically ill patient has an absolute neutrophil count of 1,000 cells/mm3 . The nurse assesses a single patient temperature of 101°F; subsequent temperatures were normal, and the patient reports no other new symptoms
What is the best nursing action? A) Assume that the elevated temperature was erroneous. B) Evaluate for acute infection. C) Assess vital signs more frequently. D) Document the temperature results as usual.
The nurse recognizes that a sign indicative of hypoglycemia in a premature infant is
a. blotchy skin c. jitteriness b. hypertonia d. a soft, weak cry
A client who is obese tells the nurse that malnutrition is definitely not a problem. The nurse responds by telling the client that:
1. Malnutrition can be an excess or deficiency of nutrients. 2. Nutrient deficiency is the best indicator of malnutrition. 3. This is correct information. 4. A lot of research about malnutrition is being conducted.
Examples of advocacy include which of the following?
a. A nurse may relate the client's desires for treatment to the physician. d. A nurse spends quality time with clients. b. A nurse arranges an opportunity for the client to share treatment desires with the physician. e. A nurse discourages clients from discussing their condition openly with their physician. c. A nurse takes action when clients are shortchanged because of treatment costs.