While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate?

Question

a. Increase the inflation pressure in the tracheostomy cuff.
b. Add blue dye to a beverage to assess for aspiration.
c. Make the client NPO and notify the health care provider.
d. Perform a more thorough assessment of the client.

Answer 1

D
Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.