The nurse is planning care for a client with an oral endotracheal tube

The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this client’s plan of care?

1. Insert an oropharyngeal airway.
2. Provide nasal care every 2 to 4 hours.
3. Provide oral hygiene every 2 to 4 hours.
4. Adjust non-humidified airflow as prescribed.
5. Move the tube to opposite sides of the mouth every 8 hours.

ANSWER

Correct Answer: 1, 2, 3, 5

Rationale 1: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube.

Rationale 2: For an oral endotracheal tube, provide nasal care every 2 to 4 hours.

Rationale 3: For an oral endotracheal tube, provide oral hygiene every 2 to 4 hours.

Rationale 4: Provide humidified air or oxygen because the endotracheal tube bypasses the upper airways, which normally moisten the air.

Rationale 5: For an oral endotracheal tube, move the tube to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa.