While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse's first nursing action?
a. Press the emergency response button.
b. Place the patient on a face mask delivering 100% oxygen.
c. Insert a spare tracheostomy without the obturator.
d. Manually occlude the tracheostomy with sterile gauze.
C
The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used, but it is not life threatening to omit this. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy has an impairment that causes him not to be able to breathe normally; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate.
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