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 C
Explanation
A. PT/INR: PT/INR is used to assess clotting function and liver synthetic function but does not directly relate to the symptoms of lethargy and confusion.
B. Urea: Urea levels are related to kidney function and protein metabolism but do not directly explain the symptoms of encephalopathy.
C. Ammonia: Elevated ammonia levels in cirrhosis can lead to hepatic encephalopathy, which presents as lethargy and confusion. The liver is unable to convert ammonia to urea, leading to its accumulation in the blood.
D. Albumin: Albumin levels are important in assessing nutritional status and fluid balance in cirrhosis but do not directly cause lethargy and confusion.
Correct Answer is B
Explanation
A. An increase in O2 saturation to greater than 90%: An increase in oxygen saturation is typically a positive sign and does not indicate worsening heart failure.
B. The onset of atrial fibrillation: The development of atrial fibrillation in a patient with heart failure is a sign of worsening heart failure, as it indicates increased atrial pressure and the potential for further hemodynamic compromise.
C. Louder S1 and S2 heart sounds: Louder heart sounds do not specifically indicate worsening heart failure. They may vary based on other factors such as body habitus or the position of the patient.
D. A decrease in heart rate to 66 bpm: A heart rate of 66 bpm is within the normal range and does not suggest worsening heart failure.
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