Asked by Rafael Summo on Jun 17, 2024
Verified
The nurse is assessing a patient who is intubated and on a ventilator.When listening above the sternal notch with a stethoscope,the nurse notes a minimal amount of air leak at the end of inspiration.Which action by the nurse is appropriate?
A) Remove all air from the cuff and reinflate the cuff until no air leak is present.
B) Note that the cuff is properly inflated.
C) Notify the health care provider.
D) Suction the patient.
Intubated
The insertion of a tube into the trachea to maintain an open airway, deliver oxygen, administer medications, or remove secretions.
Ventilator
A medical device that supports breathing by moving breathable air into and out of the lungs.
Sternal Notch
The visible dip at the top of the sternum between where the collarbones meet at the base of the neck.
- Identify the appropriate actions to take when a patient shows signs of respiratory distress or decreased oxygenation during suctioning.
Verified Answer
MA
Magdoleen AluluJun 17, 2024
Final Answer :
B
Explanation :
The cuff should be inflated to minimal leak.If the air leak is audible with the ear,it is too large.A properly inflated cuff should have a minimal air leak that is heard only with a stethoscope.The air should not be removed,the health care provider does not need to be notified,and the patient does not need to be suctioned because the cuff is properly inflated.
Learning Objectives
- Identify the appropriate actions to take when a patient shows signs of respiratory distress or decreased oxygenation during suctioning.
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