NCLEX Practice Test

What is the priority nursing action after an intubated client expels the endotracheal tube while being turned?

1. Assess respiratory rate and breath sounds to ensure ventilation is occurring

2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen

3. Immediately alert the health care provider and prepare for reintubation

4. Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia

The correct answer is: Assess respiratory rate and breath sounds to ensure ventilation is occurring

After an intubated client expels the endotracheal tube while being turned, the priority nursing action is to assess respiratory rate and breath sounds to ensure ventilation is occurring. This is because the client's airway is now compromised and the nurse must ensure that they are still receiving adequate oxygenation and ventilation. Delivering rescue breathing with a bag-valve-mask attached to 100% oxygen would also be an appropriate action, but it is not the priority. This option may be more suitable if the client is not able to breathe on their own. Immediately alerting the health care provider and preparing for reintubation may also be necessary, but it is not the priority nursing action. It is important to assess the client's respiratory status first before taking further actions. Initiating a code blue to prepare for potential cardiac arrest is not appropriate as the client may just need their endotracheal tube reinserted and oxygen levels would need to be assessed before calling for a code blue. Therefore, option A is the best option as it addresses the immediate need to assess the client's ventilation and oxygenation.