When capping the client's tracheostomy tube with a speaking valve, the nurse assesses the client's breath sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this assessment finding?
1. Allowing the cap to remain in place as long as the client tolerates it
2. Documenting the placement of the cap and relevant data regarding client assessment
3. Removing the valve and notifying the health care provider
4. Assisting the client out of bed
Correct Answer: 3
The valve should be removed and the health care provider notified because lack of an air leak indicates the client will not be able to exhale and, as a result, will not tolerate the valve. Only after calling the health care provider would the nurse document the inability to use the valve. There would be no need to assist the client out of bed.
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