You are caring for a patient with a tracheostomy tube. The patient's tube becomes dislodged while you are repositioning them. What is your first course of action?
Give them pain medications
Leave the room and go get the healthcare provider
Assess patient's level or consciousness and ability to breathe
lay their bed flat
The Correct Answer is C
A. Give them pain medications: Administering pain medication is not the priority in an emergency situation like tracheostomy dislodgement. The immediate concern is airway patency and oxygenation; pain management can be addressed once the airway is secured.
B. Leave the room and go get the healthcare provider: Leaving the patient alone when their airway is compromised can result in rapid deterioration or respiratory arrest. The nurse should stay with the patient, assess breathing, and call for assistance using the emergency call system instead of leaving the bedside.
C. Assess patient’s level of consciousness and ability to breathe: Assessing consciousness and breathing determines whether the patient is getting adequate oxygenation through the natural airway or requires immediate intervention. This assessment guides the next steps, such as repositioning the tracheostomy or using a bag-valve mask if necessary.
D. Lay their bed flat: Laying the bed flat could worsen oxygenation and make airway management more difficult. Keeping the head elevated helps maintain better lung expansion and facilitates easier breathing, especially in patients with respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Unstable cervical spine: Manipulating the head and neck during oral intubation can worsen spinal injury. Alternative airway management, such as fiberoptic intubation or surgical airway, is preferred to protect the spinal cord.
B. Epiglottitis: Inserting an oral endotracheal tube can traumatize the inflamed epiglottis and airway, potentially causing complete obstruction. Epiglottitis is a contraindication to oral intubation, and careful airway planning is essential.
C. Dental abscess: While a dental abscess may increase difficulty with oral intubation, it is not an absolute contraindication. Careful technique and consideration of infection risk are required, but intubation can often proceed safely.
D. Skull fracture: Particularly fractures of the base of the skull, oral intubation may risk intracranial placement of the tube. Nasotracheal intubation is generally avoided, and alternative airway methods may be necessary.
Correct Answer is C
Explanation
A. Adjust ventilator settings when feeling it is necessary: Ventilator adjustments require a healthcare provider’s order or protocol-guided changes; the RN does not independently alter settings based solely on judgment.
B. Remove endotracheal tube when patient is improving: Extubation is a provider-driven procedure and requires clinical assessment and order; the RN cannot remove the tube independently.
C. Mark/record position of the tube at the lip or teeth: Monitoring and documenting the position of the endotracheal tube is a key nursing responsibility. This ensures the tube remains in the correct position and helps detect accidental displacement.
D. Record patient's oxygen saturation every 15 minutes: While monitoring SpO2 is important, the RN should continuously monitor and document according to facility policy. Recording is a routine assessment but does not replace critical tasks like securing and assessing tube position.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.