Health Promotion and Maintenance
75. While suctioning a child with a tracheostomy tube in place, a nurse discovers that the suction catheter will not advance inside the tracheostomy tube and the child is becoming pale and anxious, with noticeable suprasternal retractions. What should be the nurse's priority action?
. Change the tracheostomy tube at once.
. Instill normal saline into the tracheostomy tube and attempt suctioning again.
. Obtain a pulse oximetry reading.
. Auscultate lung sounds.
Test-Taking Tip
If there is enough evidence in the stem of a question that a client is experiencing a respiratory emergency, the best answer is to provide necessary action to resolve the emergency rather than taking time to gather additional assessment data.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
Health Promotion and Maintenance
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Answer 1 is correct because the child is displaying symptoms of respiratory distress due to tracheostomy occlusion since the nurse is unable to pass the catheter through the tracheostomy tube. This is an emergency requiring the nurse to promptly change the tracheostomy tube. Answer 2 is incorrect because this action puts the child at risk by delaying insertion of a new tracheostomy tube. Answer 3 is incorrect because this action puts the child at risk by delaying insertion of a new tracheostomy tube. Answer 4 is incorrect because this action puts the child at risk by delaying insertion of a new tracheostomy tube.