The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse take when ...

The answer to question 1

C
If the patient develops respiratory distress during suctioning, the catheter should be immediately withdrawn and supplemental oxygen and breaths supplied as needed. In an emergency, disconnect suction and attach oxygen at the prescribed flow rate through the catheter.

The answer to question 2

C
The advantage of the AED is that laypeople or health care providers trained in basic life support, who have less training than ACLS personnel, can defibrillate. AEDs eliminate the need for training in rhythm interpretation and make early defibrillation practical and achievable. The AED is an automated external defibrillator that incorporates a rhythm analysis system. Upon rhythm identification, some AEDs will automatically provide the electrical shock after a verbal warning (fully automated). Other AEDs will recommend a shock, if needed, and then will prompt the responder to press the shock button. The provider does not need to adjust anything.

The answer to question 3

C
In older children, the suction catheter is inserted about 16 to 20 cm or 6 to 8 inches. The catheter is always inserted during inspiration. The catheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. The procedure requires sterile gloves, at least on one hand. The trachea should be suctioned before the pharynx because the mouth and the pharynx contain more bacteria than the trachea.

The answer to question 4

D
Identify the need to insert an oral airway. Signs and symptoms include upper airway gurgling with breathing, absence of a gag reflex, increased oral secretions, excessive drooling, grinding of teeth, clenched teeth, biting of the orotracheal or gastric tube, labored respirations, and increased respiratory rate. These conditions place the patient at risk for obstruction of the upper airway. Normal response shows no evidence of airway obstruction or compromise. Wheezing may be present as a symptom of allergy but not necessarily of airway obstruction.

The answer to question 5

A
Size is correct if, when the flange is held parallel to the front teeth with the airway against the patient's cheek, the end of the curve reaches the angle of the jaw.

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