Question

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately?

1 Suction the tracheostomy.
2 Change the tracheostomy tube.
3 Readjust the tracheostomy tube and tighten the ties.
4 Perform a complete respiratory assessment.

Answer 1

The nurse should immediately perform a complete respiratory assessment to identify the cause of the noisy, increased respirations and elevated heart rate in a postoperative patient with a tracheostomy tube.

Step-by-step explanation:

If a patient post-surgery with a tracheostomy tube suddenly develops noisy, increased respirations and an elevated heart rate, the priority action a nurse should take is to perform a complete respiratory assessment. This assessment will help determine the cause of the symptoms and guide the appropriate intervention.

It is crucial to assess the airflow through the tracheostomy tube, the patient's oxygen saturation, and overall respiratory function. If the assessment indicates a blockage, then suctioning the tracheostomy tube may be necessary. However, changing the tracheostomy tube or readjusting and tightening the ties should be done based on the assessment findings and in agreement with established protocols and physician's orders.