A mechanically ventilated 2-year-old child has copious oral ...

[fnuegbu]

A mechanically ventilated 2-year-old child has copious oral secretions. What action by the nurse takes priority?
 
  A.
  Assess placement of the endotracheal tube.
  B.
  Clean and dry the skin around the mouth.
  C.
  Raise the head of the child's bed to 60 .
  D.
  Suction the oral cavity every 2 hours.

Question 2

A child on a ventilator suddenly desaturates. Which nursing action is the priority?
 
  A.
  Assess for displacement of the tube.
  B.
  Assess for obstruction of the tube.
  C.
  Ensure the ventilator is functioning properly.
  D.
  Listen to lung sounds for pneumothorax.

[scottmt]

Answer to Question 1

ANS: A
Moisture can interfere with securing the endotracheal (ET) tube, especially if tape is used. The nurse should assess the placement of the tube and then clean and dry the skin. The oral cavity should be suctioned as often as needed. Raising the head of the bed will not decrease secretions (and may cause pooling of secretions in the child's mouth) and may lead to skin problems if the child slides down in bed frequently.

Answer to Question 2

ANS: A
When a mechanically ventilated patient suddenly desaturates (oxygen saturation drops), the nurse responds using the DOPE mnemonic (displaced tube, obstructed tube, pneumothorax, equipment problem). The most common cause is a displaced tube, so the nurse should assess this first.

[fnuegbu]

TYSM

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Gracias!