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 ["A","D"]
Explanation
A. HAV: Hepatitis A is spread via the fecal-oral route, often through contaminated food or water.
B. HCV: Hepatitis C is primarily spread through blood-to-blood contact, not the fecal-oral route.
C. HDV: Hepatitis D is spread through blood contact and requires Hepatitis B for replication.
D. HEV: Hepatitis E is spread through the fecal-oral route, similar to Hepatitis A.
E. HBV: Hepatitis B is spread through blood, sexual contact, and perinatal transmission, not the fecal-oral route.
Correct Answer is ["15.94"]
Explanation
Convert the ordered dose to mcg/min:
- 10 mcg/kg/min × 85 kg = 850 mcg/min
Convert the available dose to mcg/mL:
- 800 mg = 800,000 mcg in 250 mL
Concentration = 800,000 mcg ÷ 250 mL
= 3200 mcg/mL
Calculate the infusion rate:
Infusion rate (mL/hour) = [Desireddose(mcg/min) ÷Concentration(mcg/mL)] ×60 min/hour
Infusion rate = (850 mcg/min ÷ 3200 mcg/mL) × 60 min/hour
= 15.94 mL/hour
The IV pump should be set to infuse at approximately 15.94 mL/hour to deliver the ordered dose of dopamine at 10 mcg/kg/min for a patient weighing 85 kg. This ensures the appropriate therapeutic effect.
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