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    HESI PN Exit 2023 II Proctored Exam
    Select All That Apply

    A young adult is brought to the emergency department after taking a handful of drugs.The client is unresponsive, so an endotracheal tube (ETT) is inserted.How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

    Explanation & Rationale

    Choice A rationale:Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.Choice B rationale:Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.Choice C rationale:Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.Choice D rationale:Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.Choice E rationale:Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

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