The nurse has just repositioned a child who is intubated and ...

[faduma]

The nurse has just repositioned a child who is intubated and mechanically ventilated. Which action by the nurse takes priority?
 
  A.
  Assess placement of the endotracheal tube.
  B.
  Document the condition of the child's skin.
  C.
  Ensure that the child cannot pull on tubing.
  D.
  Turn the ventilator alarms back on.

Question 2

A child is being weaned from the ventilator. He is awake and alert but getting increasingly tired. Which action by the nurse is the most appropriate?
 
  A.
  Cluster nursing care so the child is able to get uninterrupted periods of rest.
  B.
  Collaborate with other health team members to slow or stop the weaning process.
  C.
  Draw a blood sample for blood gas analysis, and compare the results to the last blood gas values.
  D.
  Have all of the child's visitors leave to allow the child to take a short nap.

[Brummell1998]

Answer to Question 1

ANS: A
Repositioning is a common cause of endotracheal tube displacement. After turning the child, the nurse should assess the tube placement as the priority. Other actions the nurse should take include documenting the condition of the child's skin and ensuring that the child cannot reach the tube or ventilator tubing and pull it out, but these do not take priority over assessing for correct tube placement. The ventilator alarms should not be turned off, even for a brief period of time.

Answer to Question 2

ANS: B
Weaning from the ventilator is an individualized process that takes into account several different parameters. A child who is becoming increasingly fatigued is not tolerating the weaning. The nurse should collaborate with other members of the health-care team to adjust the weaning process. Rest is important to the critically ill child, but is not the most important action at this time. Laboratory work should be reviewed, but the results may be normal despite the child's fatigue level at this point.

[faduma]

Excellent

[bdobbins]

TYSM