Practice Quiz

NCLEX-PN Exam Practice

Category - Respiratory

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You are changing the tape on a tracheostomy tube when the patient coughs, and the tube becomes dislodged. The initial action of the nurse should be:
  1. Cover the site with a sterile dressing.
  2. Notify the physician.
  3. Grasp the retention sutures and spread the opening.
  4. Notify the respiratory therapist.
Explanation
Answer: C - The nurse should grasp the retention sutures and spread the opening of the site. If policy allows, the nurse would then reinsert the tracheostomy or notify the physician to come reinsert the tube. The nurse should be sure not to do anything that would block the airway until the tube is reinserted.
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