The nurse is evaluating a patient to determine whether the endotracheal tube cuff is properly inflated. Which findings indicate proper inflation? (Select all that apply.)
a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator.
b. Air leak is heard with a stethoscope only at the end of inspiration.
c. The patient is able to vocalize.
d. Gastric contents are noted in airway secretions.
A, B
The exhaled tidal volume from mechanical ventilation should not be less than 50 mL of the delivered tidal volume to ensure appropriate ventilation of the lungs. The air leak should be audible only with a stethoscope at the end of inspiration. Excessive phonation and gastric secretions in the airway indicate a partially deflated cuff.
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