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NCLEX-RN

Category - Reduction of Risk

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A client’s tracheostomy tube dislodges. What is the initial action of the nurse?

Client is hyperoxygenated
Cover the tracheostomy site with a sterile dressing soaked in normal saline solution.
Spread the opening by grasping the retention sutures.
Notify the physician right away to reinsert the tube.

Explanation

Answer - C - The initial nursing action is to grasp the retention sutures to spread the opening. Covering the site with a dressing blocks the airway. Hyperoxygenating the client is not the correct initial action. Option D delays treatment; the physician should be notified immediately after the initial nursing action.

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