NCLEX-PN® ExaminationPhysiological AdaptationMedium
A client with a new tracheostomy is experiencing difficulty breathing, and the nurse notes frothy, pink secretions in the tracheostomy tube. Auscultation reveals crackles and rhonchi bilaterally. The client's oxygen saturation is 88% on 4L nasal cannula. Which action should the nurse take FIRST?
- ASuction the tracheostomy tube and apply supplemental oxygen.
- BAdminister a prescribed PRN bronchodilator.
- CNotify the physician of the client's deteriorating condition.
- DIncrease oxygen flow rate to 6L via nasal cannula.
Show answer & explanationAnswer & explanation
Correct answer: A. Suction the tracheostomy tube and apply supplemental oxygen.
Frothy, pink secretions, difficulty breathing, and decreased oxygen saturation in a client with a tracheostomy strongly suggest pulmonary edema and/or airway obstruction from secretions. The immediate priority is to clear the airway by suctioning and provide adequate oxygenation. Increasing oxygen without clearing the airway will be less effective, and notifying the physician is important but secondary to immediate airway management.
Why the other options are wrong
- B. While bronchodilators may be helpful, clearing the airway of secretions is a more immediate and direct intervention for frothy secretions and decreased O2 sat.
- C. Notifying the physician is necessary, but after immediate life-saving interventions like airway clearance and oxygenation are initiated.
- D. Increasing oxygen without clearing the airway first may not be effective if the obstruction is significant.
Tracheostomy Care & Suctioning
Management of an artificial airway in the trachea, including assessment, cleaning, and suctioning to maintain patency and prevent complications.
- Suctioning is performed to remove secretions and maintain airway patency.
- Signs of need for suctioning include adventitious breath sounds, visible secretions, ineffective cough, decreased SpO2, increased WOB.
- Sterile technique is crucial for tracheostomy suctioning to prevent infection.
Memory trick: Trach Tube Trouble? Clear the Clutter, Get Air!