The nurse has just repositioned a child who is intubated and mechanically ventilated. Which action by the nurse takes priority?
A.
Assess placement of the endotracheal tube.
B.
Document the condition of the child's skin.
C.
Ensure that the child cannot pull on tubing.
D.
Turn the ventilator alarms back on.
ANS: A
Repositioning is a common cause of endotracheal tube displacement. After turning the child, the nurse should assess the tube placement as the priority. Other actions the nurse should take include documenting the condition of the child's skin and ensuring that the child cannot reach the tube or ventilator tubing and pull it out, but these do not take priority over assessing for correct tube placement. The ventilator alarms should not be turned off, even for a brief period of time.
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