A nurse is caring for a patient with an endotracheal (ET) tube. Which of the following findings requires immediate action?
Slight movement of the ET tube during repositioning
Occasional bubbling in the oral secretions
Asymmetrical chest rise during mechanical ventilation
Minor redness around the mouth from the ET tube securement
The Correct Answer is C
A. Slight movement of the ET tube during repositioning: Minor movement of the ET tube can occur when repositioning the patient and is usually expected. It should be monitored, but it does not typically require immediate intervention if the tube remains secure.
B. Occasional bubbling in the oral secretions: Small amounts of bubbling in secretions can be normal and may indicate mild saliva accumulation or humidified air from the ventilator. This finding is not immediately dangerous but should be suctioned as needed.
C. Asymmetrical chest rise during mechanical ventilation: Unequal chest expansion suggests possible tube displacement, obstruction, or a pneumothorax. This is a serious finding that can compromise oxygenation and ventilation, requiring immediate assessment and intervention to ensure airway safety.
D. Minor redness around the mouth from the ET tube securement: Redness at the securing site is a common skin irritation due to tape or straps. It is important to monitor and provide skin care, but it does not represent an acute airway emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Comprehensive metabolic panel (CMP): A CMP provides information about electrolytes, kidney and liver function, and glucose, but it does not measure oxygenation or carbon dioxide levels. It cannot diagnose hypoxemia.
B. Oxygen saturation (SpO2): Pulse oximetry provides a non-invasive estimate of oxygen saturation, but it may be affected by poor perfusion, nail polish, or abnormal hemoglobin levels. It does not provide direct measurements of PaO2 or acid-base status.
C. Arterial blood gas (ABG): ABG is the gold standard for assessing hypoxemia because it directly measures arterial oxygen (PaO2), carbon dioxide (PaCO2), and pH. This allows precise evaluation of oxygenation and ventilation status, which is critical in acute respiratory conditions.
D. Pulmonary function test (PFT): PFTs assess lung volumes, capacities, and airflow but are not designed to detect acute hypoxemia. They are primarily used to diagnose chronic respiratory conditions like COPD or asthma.
Correct Answer is B
Explanation
A. Leave the patient to get the respiratory therapist: Leaving the patient without an airway is dangerous and can result in hypoxia or cardiac arrest within minutes. The nurse must remain with the patient, call for help, and begin manual ventilation immediately to maintain oxygenation.
B. Provide adjunct oxygenation by manually ventilating patient with a bag mask valve and 100% oxygen: When a patient self-extubates, restoring oxygenation is the highest priority. Using a bag-valve mask with 100% oxygen supports ventilation until the airway can be resecured, preventing rapid desaturation and hypoxemia.
C. Check patient’s blood pressure first: While vital signs are important, assessing and maintaining the airway takes precedence over circulatory assessment. Airway and breathing are addressed before circulation in all emergency situations according to the ABC priorities.
D. Lay patient’s bed flat: Laying the bed flat may increase aspiration risk and make manual ventilation more difficult. Keeping the head of the bed elevated or in a neutral position allows for easier airway access and promotes better ventilation.
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