Asked by Jordan Paige on May 10, 2024
Verified
The nurse is working on a long-term rehabilitation unit,is providing care for a 46-year-old woman who was the victim of a violent crime and suffered a head injury.The patient has an endotracheal tube,which is secured with tape.The tape is crusted with dried secretions.The nurse is providing personal hygiene for the patient and needs to replace the tape.What is the best way for the nurse to remove the tape?
A) Soak it with warm moist washcloths.
B) Pull it gently away from the skin.
C) Saturate it with denatured alcohol.
D) Soak it with adhesive remover.
Endotracheal Tube
A tube placed through the patient's mouth or nose into the trachea to maintain an open airway, deliver oxygen, anesthesia, or medication, and to facilitate ventilation.
Adhesive Remover
A substance used to easily remove adhesive substances from surfaces, including skin, without causing damage.
Dried Secretions
Accumulated fluids that have hardened on the skin or on mucous membranes due to evaporation or absorption.
- Comprehend the preliminary evaluations and recommendations for administering oral hygiene to patients who are unconscious.
Verified Answer
SP
Silver PhillipsMay 16, 2024
Final Answer :
A
Explanation :
When patients have nasogastric,feeding,or endotracheal tubes inserted through the nose,change the tape,anchoring the tube at least once a day.When the tape becomes moist from nasal secretions,the skin and mucosa can easily become macerated (softened by soaking).Friction from a tube causes tissue injury.Anchor tubing correctly with tape or fixative devices to minimize tension or friction on the nares.Pulling away gently is preferred after soaking with warm moist clothes.Alcohol and adhesive remover are not recommended.
Learning Objectives
- Comprehend the preliminary evaluations and recommendations for administering oral hygiene to patients who are unconscious.