After a patient has been intubated, the nurse should immediately check for placement by
1. assessing for bilateral chest expansion.
2. obtaining a chest x-ray.
3. auscultating bilateral lung fields and over the epigastrium.
4. using a disposable O2 detector.
3
Rationale: Placement should be assessed immediately following intubation. The nurse should auscultate over both lung fields to ensure equal air exchange. It is equally important to auscultate over the epigastrium to verify that there is no air exchange heard there. Assessing for bilateral chest expansion is an added assessment but by no means would be considered better than auscultation. Obtaining a chest x-ray is generally done after auscultation. Using a disposable O2 detector is not an appropriate intervention.
Cognitive Level Applying
Nursing Process: Assessment
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