Author Question: The nurse is assessing a patient who is intubated and on a ventilator. When listening above the ... (Read 26 times)

jasdeep_brar · **on:** Jun 25, 2018

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.

Question 2

The nurse is performing CPR on an adult patient who has an endotracheal tube in place. At what rate does the nurse, who is alone, administer breaths?

a. 8 per minute
b. 12 per minute
c. 20 per minute
d. 24 per minute

Danny Ewald · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

B
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.

Answer to Question 2

A
Rescue breaths for CPR with an advanced airway (endotracheal tube/tracheotomy) are given at 8 to 10 breaths/min.