Nursing Prioritization Delegation Assignment Q 55
You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
A. Assessing for bilateral breath sounds and symmetrical chest movements.
B. Auscultating over the stomach to rule out esophageal intubation.
C. Marking the tube 1 cm from where it touches the incisor tooth or nares.
D. Ordering a chest radiograph to verify that tube placement is correct.
Correct Answer: C. Marking the tube 1 cm from where it touches the incisor tooth or nares
The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. If the patient has an endotracheal tube, check for tube slippage into the right mainstem bronchus, as well as inadvertent extubation.
Option A: Auscultate over the epigastrium to assess for the absence of sounds in the stomach. The presence of an enlarging abdomen or audible air inflation into the stomach with each positive-pressure ventilation may be the initial sign of an ET tube in the esophagus or an esophageal intubation.
Option B: Since the advent of ET intubation, the use of physical examination methods has been the mainstay for the initial evaluation of proper ET tube placement. Direct visualization of the insertion of the ET tube through the vocal cords and into the trachea is the first method to confirm proper ET tube placement.
Option D: A chest X-ray is often acquired following placement of an endotracheal tube (ET tube) to determine the position of its tip. The priority at this time is to verify that the tube has been correctly placed. The trachea, carina and main bronchi are almost always identifiable on a chest X-ray image, as long as the image is viewed on a high quality screen in a darkened room.