Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient's oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.
ANS: B
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.
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