The male client who has an endotracheal tube (ET) to a mechanical ventilator expresses concern about his safety when the nurse is not visible at the bedside. Which does the nurse explain to the client about his safety?

Question

1. The endotracheal tube is repositioned every 24 hours.
2. Communication signals are used to call for assistance.
3. Endotracheal tube cuff is maximally inflated at all times.
4. Suctioning is applied to maintain a clear airway frequently.

Answer 1

2
2. The nurse explains how communication signals provide the client with a constant means of communication and, then instructs the client on using signals, including the call bell or tapping on the side rail. The nurse explains that the client will receive frequent instructions about using the signals and asks the client to provide feedback on the effectiveness of the communication signals as frequently as necessary. In ad-dition, the nurse tells the client that the nurse monitors the client very frequently and, although the nurse is potentially not visible, the client receives monitoring.
1. The ET is repositioned every day to prevent perioral skin breakdown; however, the client probably is not referring to this. Many clients who are intubated and alert worry about choking because the ET can cause a choking sensation in the trachea.
3. The cuff is inflated to a suitable level to prevent aspiration of oral secretions but not tight enough to cause tissue damage.
4. The nurse explains to the client that the ET is suctioned as needed; ET suctioning is not performed prophylactic ally because the potential benefit does not outweigh the risk.