57. A client with a tracheotomy just pulled out the tracheal tube. Which action by a RN is correct?
. Call the respiratory therapist to reinsert the tracheal tube.
. Get a hemostat to open the tracheotomy, and then try to reinsert the tube.
. Give 100% O2 by mask over the stomal opening.
. Place mouth to stoma and ventilate every 5 seconds.
Test-Taking Tip
See Answer 2 with the word "open" in the stem. Look for a nursing action that will best keep the airway open and ensure adequate ventilation.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because this delays reestablishing the airway. Answer 2 is correct because keeping the airway open is most important. Concern for contamination of the tube can be addressed after a patent airway is established. Answer 3 is incorrect because keeping the airway open is most important. Answer 4 is incorrect because reinserting the tracheostomy tube is a more effective way to ventilate the client.