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

Answer and Explanation

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.

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Correct Answer is ["B","C","D"]

Explanation

A. Instruct the patient to lie on the Left side: The patient should lie on their right side (the biopsy side) to apply pressure and prevent bleeding.

B. Assess the patient's vital signs: Monitoring vital signs is crucial to detect signs of bleeding, hypovolemia, or shock.

C. Assess the dressing over the puncture site: Checking for bleeding or hematoma formation at the puncture site is important to detect complications.

D. Assess for signs/symptoms of a pneumothorax: A pneumothorax is a possible complication of liver biopsy, especially if the biopsy needle punctures the lung.

A. "To the best of your knowledge, are your immunizations up to date?" B. "Have you ever worked in an occupation where you might have been exposed to toxins?" C. "How many alcoholic drinks do you typically consume in a week?" D. "Has anyone in your family ever experienced symptoms similar to yours?"

Correct Answer is C

Explanation

A. "To the best of your knowledge, are your immunizations up to date?" Immunization status is important but is not directly related to the symptoms of jaundice and increased abdominal girth.

B. "Have you ever worked in an occupation where you might have been exposed to toxins?" While toxin exposure could contribute to liver disease, it is less likely the immediate cause compared to alcohol consumption.

C. "How many alcoholic drinks do you typically consume in a week?" Alcohol consumption is a major risk factor for liver disease, which can lead to jaundice and ascites (increased abdominal girth).

D. "Has anyone in your family ever experienced symptoms similar to yours?" Family history is less relevant for acute symptoms of jaundice and abdominal girth, which are more likely related to lifestyle factors like alcohol use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has just undergone a percutaneous liver biopsy. Which of the following are included in the post-procedure assessment? (select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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Explanation

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