A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place?
1. Count the client's respirations.
2. Assess the depth of the client's respirations.
3. Auscultate for bilateral breath sounds.
4. Deflate the cuff and listen for minimal leak.
Correct Answer: 3
Rationale 1: Counting the respirations does not assess tube placement.
Rationale 2: This will not determine tube placement.
Rationale 3: The end of the endotracheal tube should sit just above the bifurcation of the trachea into the two mainstem bronchi. If the tube is in the correct position, the nurse should be able to hear equal bilateral breath sounds.
Rationale 4: Deflating the cuff and listening for minimal leak is a way to prevent damage to the trachea, not a way to assess placement.
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