The nurse is caring for a patient with an oral endotracheal tube in place.Which intervention by the nurse demonstrates proper procedure when providing endotracheal tube care?
A)Determining proper endotracheal tube depth by noting the length of tube beyond the gum line
B)Instructing the assistant to hold the tube away from the lips while changing the tape
C)Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube
D)Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours

Question

Quizplus · Accepted Answer

The endotracheal tube should be repositioned to the opposite side or at the center of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth.The proper depth of the endotracheal tube is determined by noting the centimeter mark at the lip or gum line.This line is marked on the tube and is recorded in the patient's record at the time of intubation.The tube should not be held away from the lips because this allows too much "play" in the tube and increases the risk for tube movement and accidental extubation.The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube.

The Nurse Is Caring for a Patient with an Oral