While the nurse prepares to suction the patient's tracheostomy tube, the patient coughs up mucus, which is visible at the opening of the tube. Which action by the nurse is most appropriate at this time?
a. Hyperoxygenate this patient.
b. Suction the visible secretions.
c. Listen to the lung sounds.
d. Wipe the mucus off with tissue.
B
The secretions need to be suctioned to remove them; then the patient would be hyperoxygenated. There is no reason to push secretions into the patient. Listening to the lung sounds will be done after suctioning to determine the effectiveness and whether the patient's airway is clear. Wiping the secretions with a tissue would bring nonsterile tissue to the opening of the tube, which is contraindicated. The fibers could also go down the tube.
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