CMSRN Medical-Surgical Nursing

Category - Pulmonary

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A client who is diagnosed with respiratory failure is intubated and is being mechanically ventilated. The client pulls out the endotracheal tube. What is the priority action of the nurse to take?

Administer oxygen via a 100% nonrebreather mask.
Ensure that the client’s airway is open.
Prepare for reintubation.
Provide nasotracheal suctioning.

Explanation

Answer - B - The priority intervention when a client loses an artificial airway is to ensure that the airway is open and patent. Once the airway is maintained, supportive ventilation and oxygenation can be provided and preparation for reintubation can be done, if needed.

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