The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
a) Assess capillary refill.
b) Obtain vital signs.
c) Auscultate lung sounds.
d) Monitor heart rhythm.
Answer: c) Auscultate lung sounds.
Explanation:
Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data. pg. 507
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