For a male client with an endotracheal (ET) tube, which nursing action is most essential?
A. Auscultating the lungs for bilateral breath sounds.
B. Turning the client from side to side every 2 hours.
C. Monitoring serial blood gas values every 4 hours.
D. Providing frequent oral hygiene.
Correct Answer: A. Auscultating the lungs for bilateral breath sounds.
For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Adventitious breath sounds such as wheezes and crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement. Although the other options are appropriate for this client, they’re secondary to ensuring adequate oxygenation.
Option B: Turn the client every 2 hours. Turning mobilizes secretions and helps prevent ventilator-associated pneumonia. Auscultate the lungs for the presence of normal or adventitious breath sounds.
Option C: Assess arterial blood gases (ABGs). Signs of respiratory compromise including decreasing Pao2 and increasing Paco2. Monitor oxygen saturation prior to and after suctioning using pulse oximetry. This assessment provides an evaluation of the effectiveness of therapy.
Option D: Brush teeth two to three times per day with a soft toothbrush. Chlorhexidine-based rinses may also be incorporated into oral care protocols. Oral care reduces colonization of the oropharynx with respiratory pathogens that can be aspirated into the lungs.
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