After an endotracheal intubation is performed, bilateral breath sounds can be auscultated. No epigastric gurgling can be heard, and there is an audible gurgle from the client's mouth. Which intervention should the nurse implement?
Check the endotracheal tube cuff pressure.
Administer a PRN sedative.
Assess client for trauma to the tongue.
Prepare for urgent reintubation.
The Correct Answer is A
Rationale:
A. Check the endotracheal tube cuff pressure: An audible gurgling sound from the mouth after intubation indicates an air leak around the endotracheal tube cuff. Inadequate cuff inflation allows air to escape during ventilation, producing this sound. Verifying and correcting cuff pressure helps ensure an effective seal and adequate ventilation.
B. Administer a PRN sedative: Sedation may be indicated for comfort or ventilator synchrony, but it does not address the mechanical cause of an audible air leak. The presence of bilateral breath sounds and absence of epigastric gurgling suggest correct tube placement. Sedation without correcting the cuff issue could delay appropriate airway management.
C. Assess client for trauma to the tongue: Tongue trauma can occur during intubation, but it would not cause gurgling related to ventilation. The described findings point toward an airway seal problem rather than oral injury. Airway patency and ventilation effectiveness take priority.
D. Prepare for urgent reintubation: Reintubation is indicated if tube placement is incorrect or ventilation is ineffective. Bilateral breath sounds and absence of gastric sounds confirm tracheal placement. The issue is more consistent with a cuff leak, which should be addressed before considering reintubation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Blood draining from the client’s mouth: Oral bleeding may result from facial trauma, lacerations, or dental injury after a motor vehicle collision. It does not specifically indicate a basilar skull fracture and lacks the characteristic signs associated with cerebrospinal fluid (CSF) leakage.
B. Blood pressure decreased to 110/64 mm Hg: This blood pressure remains within an acceptable range and may reflect pain, anxiety, or early fluid shifts. It does not confirm a basilar skull fracture and is not a hallmark neurological or cranial finding.
C. Halo around blood dropped on gauze: A halo or ring sign indicates the presence of cerebrospinal fluid mixed with blood, which strongly suggests a basilar skull fracture. CSF leakage commonly occurs from the nose or ears due to a fracture at the base of the skull.
D. Clots of blood forming within nares: Blood clots in the nose are common after facial or nasal trauma. While epistaxis can occur with skull fractures, clot formation alone does not specifically indicate a basilar skull fracture or CSF involvement.
Correct Answer is ["667"]
Explanation
Calculation:
- Identify the total volume and infusion time
Total Volume: 500 mL
Infusion Time: 45 minutes (0.75 hours)
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 500 ÷ 0.75
Infusion Rate = 666.67 mL/hr
- Round to the nearest whole number
= 667 mL/hr
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