A patient with a new tracheostomy is found lying flat with increasing work of breathing. The tracheostomy tube is still in place, and the oxygen saturation is 94%. What should the nurse do first?
Correct answer: A. Raise the head of the bed and assess breathing
- A. Raise the head of the bed and assess breathing
- B. Remove the tracheostomy tube to improve airflow
- C. Give oral fluids to loosen airway secretions
- D. Ask the patient to walk to improve ventilation
Explanation
Raising the head of the bed can immediately improve lung expansion and reduce the work of breathing. The nurse then assesses airway patency, respiratory effort, oxygenation, and tracheostomy equipment. Removing a secure tracheostomy tube without assessment can create a life-threatening airway problem.
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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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