Saunders Respiratory Practice

What should a nurse prioritize if a client attached to mechanical ventilation pulls out their tracheostomy tube?

1. Contact the physician

2. Check the client for spontaneous breathing

3. Provide oxygen via a mask

4. Reinsert the tracheostomy tube

The correct answer is: Check the client for spontaneous breathing

Prioritizing checking the client for spontaneous breathing is crucial in this scenario because it directly assesses whether the patient can breathe independently after the accidental removal of their tracheostomy tube. In the event the client is unable to breathe spontaneously, immediate action is required to secure the airway and ensure adequate oxygenation. If the patient is breathing spontaneously, it may indicate that immediate reinsertion of the tracheostomy tube is not necessary, and other supportive measures can be taken. Understanding the patient's respiratory function at this moment helps determine the subsequent steps in management. While contacting the physician is important for follow-up care, immediate assessment of the patient’s respiratory status takes precedence. Providing oxygen via a mask can be a part of the intervention later, but the priority is to evaluate the client's ability to breathe. Reinserting the tracheostomy tube is often a critical step, yet it should only be performed after ensuring the patient cannot breathe on their own or if other protocols allow for such action without delay. Therefore, the first step must focus on assessing the client's own respiratory function.