The nurse is assessing a patient with an endotracheal tube and ...

[mrsjacobs44]

The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when standing by the patient. Which intervention should the nurse perform first to address this problem?
 
  a. Deflating the cuff of the endotracheal tube
  b. Repositioning the patient or tube
  c. Inserting a new endotracheal tube
  d. Notifying the health care provider

Question 2

A client is getting up for the first time after a period of bed rest. The nurse should first:
 
  A. Assess respiratory function
  B. Obtain a baseline blood pressure
  C. Assist the client with sitting at the edge of the bed
  D. Ask the client if he or she feels light-headed

[jsm54321]

Answer to Question 1

B
If an air leak is audible with the ear, it is too large. Repositioning the patient or the tube may correct the problem. Reinflation of the cuff may be necessary. Prepare for insertion of a new tube by the health care provider or trained personnel if the cuff ruptures. Repositioning and reinflating the cuff are performed before the health care provider is notified.

Answer to Question 2

B
B. When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure.
A. Assessing the client's respiratory function is not the nurse's first intervention when getting a client up for the first time after prolonged bed rest.
C. After the nurse assesses the client's blood pressure, the nurse can assist the client to a sitting position at the side of the bed.
D. After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels light-headed.

[mrsjacobs44]

TY

[jsm54321]

You're welcome