The nurse assesses the port balloon on the ETT (endotracheal tube) of an intubated patient and is unsure if the balloon is properly inflated. What is the nurse's best action?
Notify the health care provider
Call respiratory therapy to obtain the pressure within the balloon
Add air to the balloon port
Remove air from the balloon port
The Correct Answer is B
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["136.67"]
Explanation
Calculation:
The P/F ratio is calculated as:
P/Fratio= PaO₂÷ FiO₂
P/Fratio = 82÷0.60
=136.67
Correct Answer is A
Explanation
A. ST segment elevation: ST segment elevation is a classic sign of myocardial injury, indicating that a portion of the heart muscle is not receiving enough oxygen and is actively injured.
B. Q wave: A Q wave typically appears later, representing a previous myocardial infarction (necrosis), not acute injury.
C. Inverted T wave: This indicates myocardial ischemia, which is a precursor to injury but not indicative of injury itself.
D. ST segment depression: This is typically associated with ischemia or subendocardial infarction, not full-thickness myocardial injury.
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