The nurse is caring for a patient on mechanical ventilation. The nurse determines that the endotracheal tube is properly placed by which assessment?
a. Auscultating both lungs and watching the rise and fall of both sides of the chest
b. Monitoring and comparing the blood pressure in both arms
c. Observing and measuring inspiratory and expiratory rates
d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings
A
Verify placement of the endotracheal tube by auscultating the lungs and assessing chest wall symmetry. This ensures that the tube has not migrated into the right main stem bronchus. Many factors can cause blood pressure fluctuations and fluctuations in respiratory rate. Always assess the patient first. Once the patient is determined to be safe, the settings for the ventilator alarm can be checked as well.
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