The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this client's plan of care?
1. Insert an oropharyngeal airway.
2. Provide nasal care every 2 to 4 hours.
3. Provide oral hygiene every 2 to 4 hours.
4. Adjust non-humidified airflow as prescribed.
5. Move the tube to opposite sides of the mouth every 8 hours.
Correct Answer: 1, 2, 3, 5
Rationale 1: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube.
Rationale 2: For an oral endotracheal tube, provide nasal care every 2 to 4 hours.
Rationale 3: For an oral endotracheal tube, provide oral hygiene every 2 to 4 hours.
Rationale 4: Provide humidified air or oxygen because the endotracheal tube bypasses the upper airways, which normally moisten the air.
Rationale 5: For an oral endotracheal tube, move the tube to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa.
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