The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next?
a. Offer reassurance to the patient.
b. Bag the patient at an FIO2 of 100%.
c. Listen to the patient's breath sounds.
d. Notify the patient's health care provider.
ANS: C
The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.
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