A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position slightly since insertion, the nurse would assess the
a. results of the chest x-ray film taken 2 hours earlier.
b. current oxygen saturation readings.
c. status of the client's breath sounds.
d. position of the numbers on the ET tube at the lip line.
D
The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tube's side. If the tube slips, its correct position can be quickly established. Then the nurse should listen to lung sounds.
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The nursing student is learning about the appropriate method to use when assessing a client's blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure
Which of the following is the nursing instructor's best response? 1. "You can document this value if you cannot hear the blood pressure well.". 2. "This needs to be done only when the client is developing clinical manifestations associated with shock.". 3. "You are more likely to get an accurate reading when you do it this way.". 4. "It is the best way to determine an arterial obstruction.".
MC Rural communities are sustained by informal support networks and decreased mobility; whereas, in urban communities
A. Informal support networks sustain the neighborhoods in communities. B. Diversity of populations encourages close interpersonal interactions. C. Mobility of populations and complex interpersonal interactions can lead to decreased social support. D. Fear of becoming close to neighbors inhibits development of support systems.
The unique property of the heart that allows it to initiate its own electrical stimulation is known as ________.
A. autorhythmicity B. conductivity C. excitability D. contractility
MC Endotracheal tube or tracheostomy tube cuffs are inflated to minimal occlusive volume. Adequate occlusion is determined using a stethoscope to
A. hear a hissing sound over the suprasternal notch on expiration B. hear a hissing sound over suprasternal notch on end inspiration C. hear the client speak softly on exhalat D. inflated cuff pressure greater than client's blood pressure.