Fundamentals of Nursing Q 15
The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this?
A. This is a normal finding.
B. There is a leak.
C. There is an occlusion.
D. The endotracheal tube is displaced.
Correct Answer: B. There is a leak.
When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client’s mouth. Because the cuff blocks the flow of air around the tube, speech is not possible. Once the tube is removed (called extubation), the patient will be able to speak. The voice may sound hoarse and the patient may have some throat discomfort for the first few days.
Option A: Verbal sounds in an intubated patient is not a normal finding. As long as the patient has an endotracheal tube in place, the cuff will need to be inflated. An inflated cuff will prevent the patient from being able to speak. Speech is produced when we exhale air through the vocal cords, causing them to vibrate.
Option C: Without a gag reflex, saliva would enter the windpipe. This is called aspiration. It was hypothesized that the high minute volume of patients contributes to the inspissation of secretions. It is also possible that some characteristic of the Pneumocystis organism in secretions causes altered adherence characteristics of the sputum, resulting in this problem.
Option D: If the patient has complete obstruction of the upper airway, a displaced tracheostomy tube will result in immediate respiratory distress and can lead to respiratory arrest. If the patient has an intact or at least a partially open upper airway, the displaced tube may not cause an immediate problem. Therefore, displacement of the tracheostomy tube may not be obvious in the patient with a partial airway.