The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first?
Notify the patient's health care provider.
Bag the patient at an FiO2 of 100
Offer reassurance to the patient.
Listen to the patient's lung sounds.
The Correct Answer is D
Choice D rationale
Assessing the patient's respiratory status is the priority when tube displacement is suspected. Moving from 21-cm to 24-cm indicates the tube has slipped deeper, likely into the right mainstem bronchus. This displacement prevents ventilation of the left lung, leading to hypoxia, anxiety, and restlessness. Auscultating lung sounds allows the nurse to confirm absent or diminished breath sounds on the left side, providing immediate clinical evidence of the malposition before proceeding with other interventions or notifications.
Choice A rationale
While the healthcare provider must be informed of a change in tube position and the patient's deteriorating status, this is not the first action. The nurse must first perform a rapid physical assessment to determine the severity of the situation and the immediate impact on gas exchange. Clinical data, such as absent breath sounds or falling oxygen saturation, must be gathered first to provide a concise and accurate report to the provider for further orders or repositioning.
Choice B rationale
Manual ventilation with 100 percent oxygen is indicated if the patient is in severe respiratory distress or if the tube is completely dislodged. However, since the tube has moved deeper into the airway, bagging the patient without confirming the position could worsen complications or provide inadequate ventilation to the occluded lung. The nurse should first assess lung sounds to identify if the tube is in the bronchus, as the tube might simply need to be pulled back slightly.
Choice C rationale
Reassuring the patient is a supportive measure but is not the priority when there is an objective sign of airway compromise and physiological distress. The patient's anxiety and restlessness are clinical symptoms of hypoxia caused by the displacement of the endotracheal tube to the 24-cm mark. Addressing the underlying physiological cause by assessing the airway and ensuring adequate ventilation is the most effective way to reduce the patient's anxiety and ensure their safety and stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is 80 kg × 5 mg/kg = 400 mg.
Step 2 is 400 mg ÷ (150 mg ÷ 3 mL) = 8 mL. Final calculated answer is 8 mL.
Correct Answer is A
Explanation
Choice A rationale
Elevating the head of the bed to 30 to 45 degrees is the primary evidence-based intervention to prevent aspiration in patients receiving enteral feedings. This position uses gravity to keep gastric contents in the stomach and reduces the risk of reflux into the esophagus and oropharynx. Reducing the volume of potential aspirate near the glottis significantly lowers the incidence of ventilator-associated pneumonia and other pulmonary complications in the intensive care setting.
Choice B rationale
While maintaining cuff pressure is important for ventilation, it does not provide an absolute barrier against aspiration. Micro-aspiration can still occur around the cuff as secretions leak into the lower respiratory tract. The cuff is designed more to seal the airway for positive pressure ventilation than to prevent gastric reflux. Relying solely on the cuff without addressing patient positioning is insufficient for total aspiration risk management according to current clinical guidelines.
Choice C rationale
Oral hygiene is essential for reducing the bacterial load in the mouth, which can decrease the risk of pneumonia if aspiration occurs. However, performing it every 2 hours or removing the bite block does not directly prevent the mechanical movement of stomach contents into the lungs. While oral care is a vital component of the ventilator bundle, head of bed elevation remains the most direct physical deterrent to the upward migration of gastric fluids.
Choice D rationale
Chest physiotherapy is used to mobilize secretions that are already present in the lungs so they can be suctioned. It is a reactive or maintenance treatment rather than a preventive measure for aspiration. In fact, certain positions used during chest physiotherapy might actually increase the risk of reflux if the head is lowered. This intervention does not address the primary mechanism of gastric content aspiration in a patient with a feeding tube.
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