The nurse is concerned that an intubated patient is experiencing a cuff leak. Which assessment data would support the nurse's concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected

Question

Select all that apply. 1. Increased temperature
2. The patient saying, "My neck hurts"
3. Edema of the upper extremities
4. A hissing sound heard over the trachea on expiration
5. Bubbling secretions at the corner of the patient's mouth

Answer 1

2,4,5
Rationale 1: An increased temperature could result from pneumonia or other infection but is not directly associated with a cuff leak.
Rationale 2: The patient's ability to speak indicates air is leaking around the endotracheal tube.
Rationale 3: Patients on a mechanical ventilator often develop edema of the upper extremities. This finding is not associated with cuff leak.
Rationale 4: Any sound of escaping air heard on expiration could be caused by too low a volume in the ET cuff. This could be related to a cuff leak.
Rationale 5: Bubbling oral secretions may indicate cuff leak.