The nurse assesses a patient's endotracheal cuff pressure to be 22 mm Hg. The purpose for assessing the cuff pressure is to
1. check endotracheal tube placement.
2. facilitate a nasogastric tube feeding.
3. ensure adequate blood flow to the trachea and surrounding tissues.
4. determine if suctioning is needed.
3
Rationale: Endotracheal cuffs can cause potentially severe tracheal and laryngeal injuries. The use of excessive cuff pressures is the major contributing factor in these injuries. Proper monitoring and control of cuff pressures decreases the risk of complications significantly. Cuff pressures must be monitored at least once every shift and safe cuff pressure ranges from 20 to 25 mm Hg. The nurse is not assessing the patient's cuff pressure to check for endotracheal tube placement or to facilitate a nasogastric tube feeding. Cuff pressure will not assist in determining if the patient needs to be suctioned.
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Standard Text: Select all that apply. 1. What is the client's language preference? 2. Is there a name or category used by the client to identify the condition? 3. What role does religion play in the individual's life? 4. What kind of support system does the client have? 5. What is the client's educational status?
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