A nursing student is assigned to a client with an endotracheal tube on a ventilator. Upon entering the client’s room the primary care nurse is alerted by observing which of the following?
The client is wearing an intermittent compression device on each leg.
Number 3 is correct.
The presence of normal saline is of concern as it should not be used in the endotracheal tube to promote secretion removal. The head of the bed should be elevated 30 – 45 degrees at all times to prevent ventilator-associated pneumonia. The cuff on the endotracheal tube should be sufficiently inflated to ensure the patient receives proper ventilator parameters. Wearing an intermittent compression device on both legs provides deep vein thrombosis prophylaxis, an appropriate measure.
