Airway management 4
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| A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care? | On a routine schedule according to agency policy to reposition the tube.
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| Which situation can be delegated to nursing assistive personnel (NAP) in regard to endotracheal tube care? | Assisting the nurse during a tape change by holding the endotracheal tube.
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| Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care? | A sudden drop in oxygen saturation.
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| Which of the following is an inaccurate statement in regard to performing endotracheal tube care? | When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff.
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| The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally, what signs of pain should the NAP report? | Increased restlessness or a sudden change in vital signs.
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| Identify the situations that require endotracheal tube care. | -Soiled or loose tape.
-Pressure sore on naris or corner of mouth.
-Foul odor of mouth.
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| The nurse was changing the patient's tube holder on his endotracheal tube when he reached up and extubated himself. What actions should the nurse take? | -Assess the patient for spontaneous breathing.
-Administer breaths with an Ambu-bag self-inflating resuscitation bag if necessary.
-Remain with the patient and use the call system to obtain assistance.
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