While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse's first nursing action?
Manually occlude the tracheostomy with sterile gauze.
Insert a spare tracheostomy.
Press the emergency response button.
Place the patient on a facemask delivering 100% oxygen.
The Correct Answer is B
Rationale:
A. Manually occlude the tracheostomy with sterile gauze would obstruct the airway completely and is unsafe.
B. Insert a spare tracheostomy is correct because the priority is to re-establish the patient’s airway immediately. A spare tracheostomy tube of the same size (and one size smaller) should always be kept at the bedside.
C. Press the emergency response button may be necessary if reinsertion is unsuccessful, but it is not the first action.
D. Place the patient on a facemask delivering 100% oxygen is not effective because the tracheostomy stoma is the patient’s airway, and oxygen delivery via face mask would not ventilate the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The prescriber is responsible for writing a clear and legible order, but the nurse should have clarified before administering.
B. The pharmacist helps verify medication orders but does not administer the medication.
C. The nurse is ultimately responsible for ensuring the order is clear and safe before administration. Administering a drug without clarification makes the nurse accountable for the error.
D. Errors are not considered “no fault”; accountability and corrective action are necessary to protect patient safety.
Correct Answer is A
Explanation
Rationale:
A. Rotating the tube 180 degrees during insertion helps the tube pass more easily through the nasopharynx and esophagus, reducing the chance of coiling in the throat.
B. A full 360-degree rotation is unnecessary and may cause trauma or discomfort.
C. A 90-degree rotation is insufficient to aid smooth passage of the tube.
D. A 45-degree rotation is not part of recommended NG tube insertion technique.
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