A ventilated patient suddenly becomes cyanotic, and the endotracheal tube is found outside the mouth. The oxygen saturation is falling. Which action should the nurse take immediately?
Correct answer: C. Call for help and ventilate with a bag and high-flow oxygen
- A. Increase the ventilator rate and reassess later
- B. Silence the alarm and wait for the respiratory therapist
- C. Call for help and ventilate with a bag and high-flow oxygen
- D. Reinsert the tube independently without checking equipment
Explanation
An accidental extubation is an airway emergency. Calling for help and providing bag ventilation with high-flow oxygen supports breathing while the airway is urgently assessed and secured; simply changing ventilator settings cannot correct the missing airway.
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About Critical Care and Emergency Nursing
Covers rapid assessment and stabilisation of patients with airway obstruction, respiratory failure, shock, cardiac arrest, sepsis, poisoning and major electrolyte disturbances. It includes triage, the ABCDE approach, cardiopulmonary resuscitation, ventilator and monitor care, emergency medicines and distinguishing life-threatening deterioration from stable illness.
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