The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action?
a. Nothing; this is required during ventila-tion.
b. Inflate the cuff using minimal leak tech-nique.
c. Call the Rapid Response Team.
d. Increase the tidal volume.
B
The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ven-tilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.
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