A nurse is caring for a patient following an endotracheal extubation. Which of the following is NOT a nursing care aspect in this case?

Appeared in: DSSSB -28 August 2019 (Shift-2)

Explanation

The statement to withhold mouth care is an incorrect nursing action, making it the answer to this 'NOT' question.
Gentle mouth care is essential after extubation to remove accumulated oral secretions, improve patient comfort, and maintain oral hygiene.
While care should be gentle to avoid traumatizing the mucosa, completely withholding it is inappropriate and not a standard of care.
Clearing the mouth of secretions can also help maintain a patent airway and reduce the risk of aspiration of oral bacteria.

Option A: This is a correct and essential nursing action. Providing supplemental humidified oxygen is a standard intervention immediately after extubation to support oxygenation and reduce the work of breathing.
Option B: This is a correct and critical nursing action. Close monitoring of respiratory rate, effort, and chest excursions is vital to promptly identify any signs of respiratory compromise or airway obstruction.
Option D: This is a correct and important nursing action. Keeping the patient NPO (nothing by mouth) is a crucial safety measure to prevent aspiration until the gag and swallow reflexes are confirmed to be intact.

Clinical Relevance

Nursing practice connection: Use the key finding related to Post-extubation nursing care to guide bedside assessment, documentation, and the next nursing action.
The nurse's role in the first few hours after extubation is critical for preventing life-threatening complications like acute airway obstruction or aspiration pneumonia.
A thorough assessment of airway patency, respiratory effort, and swallowing function guides nursing interventions and determines when it is safe to advance the patient's diet.
What if? If the patient develops stridor (a high-pitched, harsh sound on inspiration) within an hour of extubation, this indicates laryngeal edema and a potential airway emergency. The nurse must notify the provider immediately, maintain the airway, and prepare for interventions like nebulized racemic epinephrine or corticosteroids, and have re-intubation equipment ready.

How to Approach the Question

First, identify the negative keyword 'NOT' in the question stem. This means you are looking for the option that represents an incorrect or inappropriate nursing action.
Review the clinical context: care for a patient immediately following endotracheal extubation.
Recall the primary goals of post-extubation care: maintain a patent airway, ensure adequate oxygenation and ventilation, and prevent complications like aspiration and respiratory distress.
Evaluate each option against these goals.
Option A (Give oxygen) and Option B (Monitor respiratory rate) are standard actions to support breathing and ensure safety.
Option D (NPO) is a critical safety measure to prevent aspiration.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 113-115

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 1 p. 49-51

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 193-195

Practise the full DSSSB -28 August 2019 (Shift-2)

Attempt every question from this paper in a timed mock, then review the full solution for each one.