The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action?
a. Turn the client to the right side.
b. Elevate the head of the bed.
c. Assess placement of the endotracheal (ET) tube.
d. Suction the client.
C
The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube.
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