A patient with a new tracheostomy becomes restless and has noisy breathing. The oxygen saturation is 91%, and the nurse sees thick secretions at the tracheostomy opening. What should the nurse do first?
Correct answer: A. Assess the airway and suction the tracheostomy as indicated
- A. Assess the airway and suction the tracheostomy as indicated
- B. Offer oral fluids and reassess the oxygen saturation later
- C. Remove the tracheostomy tube to inspect the airway
- D. Ask the patient to lie flat and breathe slowly
Explanation
Restlessness, noisy breathing, and visible thick secretions suggest airway obstruction. The nurse should assess the airway and clear secretions using appropriate suction technique and emergency support if needed. Removing the tube or lying the patient flat can worsen airway compromise.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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