A nurse is starting a new shift and assessing the client who has an oral endotracheal tube in place. Which finding requires immediate intervention?
A. The client has been intubated for four days.
B. The endotracheal tube is midline in the mouth.
C. The endotracheal tube is taped to the lower jaw.
D. The client has hydrocolloid membrane on the skin of the cheeks.
C
The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much.
You might also like to view...
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care?
a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.
You detect a nonmobile fatty mass with a smooth circular edge when palpating deeply in a patient's scalp. This is most likely a
a. hematoma. c. metastatic carcinoma. b. lipoma. d. subcutaneous emphysema.
The charge nurse of a small nursing unit would like to gain staff acceptance of a time-intensive, budget-imposed change required by the hospital administration
She plans to emphasize several evidence-based research projects that have shown improved patient health outcomes as a result of implementing this change. This is an example of which of the following organizational change concepts? a. Budget-oriented change b. Transformation c. Resistance d. Emergent change
How can capacity be assessed?
What will be an ideal response?