Aug 24 ACE NCLEX with Practice Question

August 24, 2024

Saturday

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The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information.

Vital Signs

Heart rate    -132/min

Respirations -     40/min

O2 Saturation or SpO2 - 80 %

Apply a nonrebreather face mask with 100% oxygen

Apply dry, sterile gauze over the stoma and secure with tape

Insert a new tracheostomy tube using the bedside obturator

Insert a sterile catheter into the stoma and suction the airway

A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss.

If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3).

(Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma.

(Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation.

(Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply.

Educational objective: Accidental dislodgment of a tracheostomy tube is a medical emergency. With a mature tracheostomy, an attempt to insert a new tracheostomy tube with the bedside obturator is indicated. If a tube cannot be reinserted, the stoma is covered with a sterile, occlusive dressing. Ventilation is provided with a bag-valve mask over the nose/mouth.

A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss.

If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3).

(Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma.

(Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation.

(Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply.

Educational objective: Accidental dislodgment of a tracheostomy tube is a medical emergency. With a mature tracheostomy, an attempt to insert a new tracheostomy tube with the bedside obturator is indicated. If a tube cannot be reinserted, the stoma is covered with a sterile, occlusive dressing. Ventilation is provided with a bag-valve mask over the nose/mouth.

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