Practice Quiz

NCLEX-PN

Category - Reduction of Risk

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The nurse is caring for a client with a tracheostomy tube. During the morning shift, the nurse notes that the client is having difficulty breathing. Thick secretions are noted while suctioning. The nurse should first:
  1. Call for help
  2. Have the client cough and reattempt suctioning
  3. Allow the client to rest a few minutes
  4. Manipulate the tracheostomy tube
Explanation
Answer: B - Tracheostomy obstruction is often due to thickened secretions. Initially, the nurse should have the client cough to dislodge any thickened secretions in the airway. Gentle suctioning should be done after humidification of the airway. The nurse should minimize manipulation of the tracheostomy tube. If unable to provide ventilation due to the obstruction, the nurse should immediately call for help.
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