Which of the following assessments are the responsibility of the registered nurse when caring for a patient with an endotracheal tube?
Adjust ventilator settings when feeling it is necessary
Remove endotracheal tube when patient is improving
Mark/record position of the tube at the lip or teeth
Record patient's oxygen saturation every 15 minutes
The Correct Answer is C
A. Adjust ventilator settings when feeling it is necessary: Ventilator adjustments require a healthcare provider’s order or protocol-guided changes; the RN does not independently alter settings based solely on judgment.
B. Remove endotracheal tube when patient is improving: Extubation is a provider-driven procedure and requires clinical assessment and order; the RN cannot remove the tube independently.
C. Mark/record position of the tube at the lip or teeth: Monitoring and documenting the position of the endotracheal tube is a key nursing responsibility. This ensures the tube remains in the correct position and helps detect accidental displacement.
D. Record patient's oxygen saturation every 15 minutes: While monitoring SpO2 is important, the RN should continuously monitor and document according to facility policy. Recording is a routine assessment but does not replace critical tasks like securing and assessing tube position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Oral care: Regular oral hygiene helps reduce the bacterial load in the mouth and oropharynx, which can prevent aspiration of pathogens into the lungs. This is one of the most effective nursing interventions to reduce the risk of ventilator-associated pneumonia.
B. Ordering antibiotics for the patient: Nurses do not independently order antibiotics, and prophylactic antibiotics are not routinely recommended for VAP prevention. Unnecessary antibiotic use can lead to resistance and other complications.
C. Giving patient cough medications: Suppressing cough in ventilated patients is not recommended, as effective coughing helps clear secretions. Cough medications do not prevent VAP and may interfere with natural airway clearance.
D. Monitoring patient for a fever and letting the healthcare provider know if there is one: While monitoring for infection is important, this is a reactive intervention rather than a preventive measure. Oral care and other hygiene measures directly reduce VAP risk before infection occurs.
Correct Answer is B
Explanation
A. Increased sleepiness: While hypoxemia can eventually lead to fatigue or altered mental status, sleepiness is not the classic early sign of diffusion impairment in hypoxemic respiratory failure.
B. Hypoxemia is worse with activity, better with rest: Diffusion impairment limits oxygen transfer across the alveolar-capillary membrane. During activity, oxygen demand increases, and the impaired diffusion results in more pronounced hypoxemia. Rest decreases oxygen demand, allowing partial compensation.
C. Chest pain that occurs with activity and is better at rest: This is more characteristic of cardiac ischemia rather than diffusion impairment in the lungs.
D. Asymmetrical chest movement: Unequal chest movement suggests localized lung pathology, pneumothorax, or obstruction, not a global diffusion problem in hypoxemic respiratory failure.
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