The nurse changes the position of the client's endotracheal tube (ET). Which is a suitable nursing intervention?

Question

1. Hold tube firmly in place at all times.
2. Insert nasal airway if client bites ET.
3. Leave some slack in tape holding ET.
4. Suction the client after providing care.

Answer 1

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1. A very important nursing goal for the client with an ET is to prevent accidental extubation because the client needs the ET to maintain an airway. To protect the air-way, the nurse checks the security of the tube's holder and checks ET placement, making sure that the tube does not shift and the client has bilateral breath sounds.
2. The nurse inserts an oral airway for the client biting on an endotracheal tube; a nasal airway is ineffective to prevent biting on the ET because the nasal airway does not interface with the mouth.
3. The nurse maintains a snug fit on the ET holder because loose tape holding the ET allows too much movement in the tube and is likely to lead to displacement.
4. The nurse suctions the client before providing care because suctioning can cause splatter.