To verify the correct placement of an oral endotracheal tube after insertion, which actions by the nurse are appropriate? (Select all that apply)

While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best?

Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia? (Select all that apply)

A nurse is caring for a patient admitted 12 hours ago to a surgical ICU after emergent surgery for an acute ischemic bowel.The nurse has the following data: Past Medical History• Lumbar spine surgery 5 years ago• Chronic back pain controlled with oxycodone 15 mg PO tidOperative Procedure• Surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis• During surgery the systolic BP dropped to 70mm/Hg• Six units of packed red blood cells and 4L of 0.9% saline were infused• The patient is receiving 60% O2 via an aerosol face maskPostoperative Orders• Continuous ECG and pulse oximetry monitoring• Give 0.9% saline at 125mL/hr via a central venous IV catheter• Monitor hourly urine output via indwelling bladder catheter• For pain management bolus with Morphine 10mg and begin a continuous IV infusion of morphineImmediate Postoperative Status• Patient’s is restless requiring progressively higher FIO2 via high-flow face mask and a short trial of noninvasive positive pressure ventilation (NIPPV).• The patient continues to experience declining SaO2 levels and urine output decreases. Emergent endotracheal intubation and mechanical ventilation are needed.• Postintubation chest x-ray reveals 50% right-sided pneumothorax, requiring the emergent chest tube placement. Chest tube is inserted and connected to intermittent suction. Immediately after chest tube placement, the SpO2 decreased to 84%.• ABGs shows PaCO2 increased to 52mm/Hg; PaO2 has come back up to 92%.• Patient is tachycardic during insertion and remains tachycardic and restless immediately after chest tube insertion. Based on the data provided from the case study and the available postoperative orders, what is the nurse’s most appropriate intervention for the care of the patient following insertion of the chest tube? 

Postoperative Day 2• There is an advance directive in the patient’s record indicating that this patient does not want to be kept alive by artificial means.The patient remains in acute renal failure.Subjective Data• Patient is unable to communicate.Objective DataPatient was medicated with a 10mg bolus of morphine due to restlessness.Physical Examination• General: Sedated, head of bed elevated 45 degrees; skin cool with moderate diaphoresis• Respiratory: Endotracheal tube in place with mechanical ventilation. No accessory muscle use, retractions, or paradoxic breathing; respiratory rate in phase with ventilator, bilateral crackles at lung bases. Ventilator settings: A/C – Tidal Volume 450/mL, FIO2 100%, Respiratory Rate 10/minute, PEEP 10/cm H2O, pressure limit 35cm H2O.• Cardiovascular: Apical-radial pulse equal, BP 100/60mmHg• Weak peripheral pulses; temperature 101° F (38.3° C) rectally• Gastrointestinal: Surgical dressing dry and intact; colostomy draining serosanguineous drainage• Urologic: Indwelling bladder catheter draining concentrated urine less than 30mL/hrDiagnostic Findings• Arterial blood gas results include a pH of 7.20, PaO2 of 88 mm Hg, PaCO2 of 60 mm Hg, and HCO3– of 18 mEq/L. What changes to the ventilator settings will the nurse anticipate?

While caring for this mechanically ventilated patient the high pressure alarm begins to alert. Which is the nurse’s priority intervention?

Which nursing interventions should be included for the patient who has full thickness and deep partial thickness burns to 50% of their body who is receiving hydrotherapy for debridment and open method of wound care? (Select all that apply)

The nurse is teaching a patient with iron-deficiency anemia about foods to increase iron intake. Which foods should the patient be instructed to eat?

A patient is on vitamin D supplemental therapy. The nurse will monitor for which signs of toxicity during this therapy?

An elderly patient needs to take an enteral supplement to improve their overall nutritional status. When considering enteral supplements, the nurse notes that which formulation provides complex nutrients?