Author Question: The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by the ... (Read 61 times)

laurencescou · **on:** Jul 24, 2018

The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by the nurse demonstrates proper procedure when providing endotracheal tube care?

a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line
b. Instructing the assistant to hold the tube away from the lips while changing the tape
c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube
d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours

Question 2

The patient is a 74-year-old man who has been in the hospital for 4 days following an orthopedic surgical procedure. He is concerned because he has not moved his bowels every day as he did before surgery, but every other day.

Which response made by the nurse is appropriate? a. Tells the patient to put himself on over-the-counter laxatives
b. Tells the patient that daily bowel movements are not always necessary
c. Tells the patient that with increasing age, his bowel movements should increase in frequency
d. Tells the patient that she will call to get a laxative to get him back on track

javimendoza7 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
The endotracheal tube should be repositioned to the opposite side or at the center of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth. The proper depth of the endotracheal tube is determined by noting the centimeter mark at the lip or gum line. This line is marked on the tube and is recorded in the patient's record at the time of intubation. The tube should not be held away from the lips because this allows too much play in the tube and increases the risk for tube movement and accidental extubation. The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube.

Answer to Question 2

B
Reinforce with older adult patients that as long as the consistency of the stool remains normal and bowel movements occur with regularity. As long as he is able to move his bowels at least 3 times a week, he shouldn't worry about not having a daily movement. Since there is no indication of constipation the patient should not place himself on laxatives. However, since the patient is most likely less mobile and receiving strong pain medication following his orthopedic surgery (both likely to cause constipation) the nurse should monitor the situation.