A nurse is caring for a client receiving mechanical ventilation through a tracheostomy tube. What measure should the nurse employ with this client?
A) Ask the client to avoid turning in bed.
B) Perform tracheal suctioning, as needed.
C) Hyperextend the client's neck sufficiently.
D) Secure the tube in place using a sterile dressing.
B
Feedback:
The nurse should perform tracheal suctioning, as needed, because there may be a mucus plug, which could obstruct the airway and result in inadequate ventilation. Turning and repositioning the client every 1 to 2 hours helps to perfuse and ventilate all lung lobes adequately. The nurse should hyperextend the client's neck during insertion of the tracheostomy tube and not after the tube is in place. The tracheostomy tube should be held in place using a tape secured with a tie or Velcro. Sterile dressings are used to absorb drainage, not to secure the tube in place.
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