In the intensive care unit, a client is on mechanical ventilation (MV) after having undergone a fresh tracheostomy with retention sutures placed yesterday. The nurse hears the MV alarm sound and enters the room. The client is coughing, respirations are 40/min, heart rate is 132/min, and the pulse oximeter reading is 80%. The nurse also sees the tracheostomy tube lying on the client's chest. What is the nurse's immediate action?
a. Apply a rebreathing mask with high concentration oxygen at 12 L/min
b. Attempt to reinsert the tube with the obturator in place
c. Insert a sterile catheter into the stoma and suction the airway
d. Pull the retention sutures apart to lift the trachea and hold the stoma open
Ans: d. Pull the retention sutures apart to lift the trachea and hold the stoma open
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