Question

A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then:

a) Reinserts the endotracheal tube
b) Calls a code blue
c) Initiates bag-valve-mask ventilation
d) Notifies the healthcare provider

Answer 1

In a scenario where a patient in ICU unintentionally removes their endotracheal tube, the nurse should initiate bag-valve-mask ventilation to ensure continual breathing and oxygenation before other steps are taken.

Step-by-step explanation:

The subject of this question is Medicine, specifically concerning a scenario in a hospital's Intensive Care Unit (ICU) where a patient being mechanically ventilated has pulled out their endotracheal tube and the nurse must decide on the immediate action to take. The correct response would be c) Initiates bag-valve-mask ventilation. When a patient unexpectedly extubates themselves, the immediate concern is to ensure they can continue breathing and receive adequate oxygen. The nurse should assess for spontaneous breathing and, if necessary, provide ventilation with a bag-valve-mask until further assistance arrives and a decision about re-intubation can be made by a healthcare provider. Reinserting an endotracheal tube is not typically within the nurse's scope of practice and usually requires a healthcare provider. Furthermore, a code blue is generally called when the patient is unresponsive and not breathing; in this case, the question states that the nurse has assessed the patient for spontaneous breathing which indicates that the patient is responsive. Lastly, notifying the healthcare provider is important, but the immediate concern is the patient's airway and breathing.